Medicaid needs to be allowed to experiment with work requirements

The Bible, Luke 12:48, it reads, “For unto whomsoever much is given, of him shall be much required.” Much of society has functioned on this axiom since biblical times, and it has been a good thing. Our social safety net has been exempt from any requirement to receive benefits.

While that may have worked in the past, or financial reality as a nation necessitates that change. But there is a push to make sure it doesn’t, a push that is going to speed the collapse of government programs designed to help those in need that have far exceeded their mandate and will end up hurting the very people they were created to help.

{mosads}In Kentucky, like most states, Medicaid enrollment has exploded. The state’s population is 4.4 million, fully 1.4 million of whom are enrolled in the joint federal and state health insurance program for the poor. Without meaningful reform, it’s financially — and politically — unsustainable for a quarter of a state’s population to receive free health care, while those who are being asked to pay for it can barely afford their own coverage.

To address this growing problem, Kentucky implemented a work requirement for able-bodied Medicaid enrollees, specifically exempting those unable to work. This was a bridge too far for liberal activists, promptly suing the state.

A federal judge declared “arbitrary and capricious” the state’s attempt to require those without any physical or mental problems to work in order to receive benefits. “The Secretary never adequately considered whether Kentucky HEALTH would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid,” the judge ruled.

By preventing Kentucky from requiring able-bodied enrollees to contribute, even nominally, to their own care, the courts and activists caused actual harm to those they claim to care most about – the truly poor and disabled recipients of Medicaid.

Unlike the federal government, states are not allowed to run up huge debts. Since the changes Kentucky proposed in order to maintain the program were rejected by the courts, the state had to announce benefit cuts to all recipients.

Governor Matt Bevins announced “dental and vision coverage is being cut for nearly a half-million Kentuckians due to a ruling that rejected the state’s Medicaid overhaul plan.” But even those changes had to be rolled back, and now the money must come from somewhere.  That means other programs, and the Kentuckians they benefit, must be made to suffer because political activists opposed the idea of work requirements for people can work but don’t. It’s insanity.

Medicaid costs are skyrocketing, putting massive burdens on state budgets and crowding out other priorities. If states aren’t free to experiment with ways to lower costs and modernize the program, deeper and more serious cuts and elimination of benefits will inevitably follow. They have to.

Resources are finite. States can’t tax their way into financial viability, they can’t cut education spending, and they can’t print money to make up the difference. Choices have to be made, hard choices sometimes.

If states aren’t allowed to prioritize those most in need, those unable to work, for example, over those who can but are not, then Medicaid becomes a complete federal mandate the state is responsible for picking up its share of the cost.

Lost in all this is the importance of work for those who can and the dignity it instills in people. We are at a point right now where more jobs exist than people to do them. Yet we are also in a time when more people than ever are on some form of government assistance. It’s unsustainable.

Rather than being able to direct limited resources to those most in need and provide them with the best care, states are forced to eliminate benefits as they’re forced to offer more, to more people.

Medicaid long ago exceeded its original mandate. Started as a protection for those languishing in poverty, it has been expanded to include several multiples above the federal poverty level. It is becoming a broad-based health insurance program; it is not sustainable as free health care for everybody. If it isn’t allowed to return to something resembling its original purpose then it needs to be allowed to reform itself, including work requirements for able-bodied adults.

The social safety net is much wider and deeper than it was ever designed to be. Medicare and Social Security are expected to be bankrupt with 10 years, largely because politicians in Washington haven’t had the political courage to address long-known issues.

That cowardice does not exist in Medicaid, as states like Kentucky are the laboratories of our democracy and are willing to lead the way in trying new ways to ensure the program does what it was intended to do. If they aren’t allowed to follow through on those attempts, to find a better way — one that includes requiring something from those to whom much is given — more people run serious risk of being hurt.

Richard Topping is a healthcare lawyer and the CEO of Shao Inc., a digital health technology company based in Washington D.C. Topping was a DOJ attorney during the George W. Bush Administration, where he represented the secretary of HHS. He also served as counsel at the Center for Bioethics at Brigham and Women’s Hospital and Harvard Medical School in Boston.