By most accounts, the Healthy Michigan program, which gives 670,000 low-income Michiganders access to health care, has been a resounding success. Gov. Rick Snyder wrangled the Medicaid expansion into law in 2013 despite objections from some members of his own party. But with those two steps forward… well, you know.
Snyder signed Senate Bill 897 into law Friday, mandating Healthy Michigan recipients work 80 hours a month. There’s a thorough list of exemptions for the Medicaid work requirements, including pregnant women, caretakers of children under the age of 6 or disabled dependents, people with qualifying disabilities and full-time students. Work is defined broadly, including some community service, substance abuse treatment, education programs and job training, and recipients get a three-month grace period each year.
The bill was heavily revised before it made its way to Snyder’s desk. The work requirement was downgraded from 30 hours a week, aligning the requirement with those of other benefits programs. And the earlier version of the bill didn’t apply to counties with high unemployment, leading to what many identified as de facto bias against African-American recipients. That exemption was struck, avoiding a likely civil rights lawsuit and deflating some outrage. Now, this law looks a lot like what other states are already doing.
But it’s still worth a closer look. Why require work to get health care in the first place?
IT’S JUST JOBS
The bill’s sponsor, state Sen. Mike Shirkey (R-Clarklake), offered the lamest rationale: the requirement will help companies fill their job openings.
“This is all about trying to find more workers,” Shirkey said. “Right now, every business owner I know is seeking and searching for workers.”
Someone devising a plan to grow the state’s talent base or fill job openings probably wouldn’t start with tying work requirements to health care. Instead, one might look at, say, job training, transportation or child care assistance. The new bill doesn’t create new programs or include more funding to help the unemployed breach those barriers.
But it does dovetail with an executive order President Donald Trump signed in April pushing government agencies to incorporate work requirements into assistance programs, new for the Medicaid program. The Trump administration says work requirements will help lift people out of poverty and can actually improve health outcomes. While research shows higher incomes are correlated with better health, there’s little to suggest that working makes you healthier, let alone when it’s tied to your ability to get treatment. In studies of work requirements in other public assistance program, they temporarily boosted the number of recipients working in the short-term, but didn’t affect long-term employment or earnings.
WE KNOW WHAT ‘DISINCENTIVES’ MEANS
In other comments, Shirkey offers a second explanation and hints at the ideological underpinning for this kind of legislation.
“We have an obligation to review on a pretty regular basis all of our policies, all of our laws, all of our statutes that may unintentionally result in disincentives to engage in the workplace,” he said.
“Disincentives to engage in the workplace” sure sounds a lot like, “people are relying on government handouts rather than working.” You hear this argument a lot from conservatives in debates about housing assistance and food stamps, but it’s a bold leap to suggest people are resting on their laurels and declining job opportunities because a public program lets them go to the doctor when they need to. Again, it’s also not born out by the stats. “Several studies have found no adverse employment effects of Medicaid expansion under the ACA,” according to a research review by the Urban Institute think tank. So if health care access isn’t actually discouraging people from working, we’re left wondering what a work requirement will change.
Conversely, studies around the country have shown that access to Medicaid seems to have a positive impact on the ability to find a job or keep working. Locally, a University of Michigan survey of 4,090 Healthy Michigan participants found that, of the 28 percent who were unemployed, 55 percent said coverage made them better able to look for work.
ARE MEDICAID WORK REQUIREMENTS GOOD FISCAL POLICY?
The third rationale for the work requirement is both the most familiar and the most disingenuous. Conservative groups like the Michigan Chamber of Commerce and the Heartland Institute have cited the program’s high costs as a reason for implementing the policy. According to a House fiscal analysis of the legislation, the potential savings amount to $7 to $12 million annually. The bulk of that would come from shrinking enrollment — the analysis estimates between 27,000 and 54,000 fewer people would be eligible for coverage. Of course, if all those folks met the workforce requirements, the savings would be negated and costs would actually increase — it will take an estimated $20 million annually to manage reporting and compliance monitoring, plus upfront costs up to $10 million. To suggest saving the state money as one of the outcomes obfuscates how that would occur — by ending health care coverage for thousands of Michiganders.
TRUMP-PROOFING MICHIGAN’S MEDICAID PLAN
Snyder’s defense, laid out in a Medium post responding to critics, offers a fourth rationale and is perhaps the most telling. He denied that the law was about cost savings and made no mention of helping employers find workers or helping recipients get healthier through work. Instead, Snyder wrote that the aim is to “ensure the standards of our program mirror those of similar programs and other states and make our waiver likely to be approved by the federal government.” In another section, he talks about a measure to safeguard the program from the “unpredictability of an entirely different administration’s review of the waiver.”
So that’s the bottom line: with the White House making it clear that it wants work requirements baked into Medicaid coverage, and, um, the “unpredictability,” Snyder is protecting the program he birthed by making sure he’s giving the Trump administration something they’ll approve. Whether or not it’s good for all the people who get their health care through the program.
DOWN THE LINE
With an unprecedented policy, we’ll need to wait and see how this plays out before drawing final conclusions. It does seems likely that a significant number of people will lose health coverage. How that impacts other healthcare costs and the population’s overall health, we don’t know. We’re a little more certain, and pretty pessimistic about the chances that it actually leads to more Medicaid recipients entering the workforce. For the sake of a healthier Michigan, we hope this law beats the odds. –Kate Abbey-Lambertz