As more states join Kentucky in trying to impose work requirements for people who receive Medicaid, I could not help but think of a patient of mine whom I’ll call Linda.
Linda is a healthy 42-year-old woman who came in a few months ago with pain in her left foot.
“Every morning when I wake up, it’s like a knife in my heel” she said, grimacing, and held her foot up for me to see.
“Is it cancer? It’s so painful. What could cause that pain?”
I examined her tender foot and launched into my well-practiced explanation of the problem: plantar fascitis, an inflammation of the tissues connecting the heel and toes, which is very common and in some cases very painful. I swiveled back from the computer with a handout and was stunned to see Linda weeping in relief. “I just, I really thought it was a tumor in my bone,” she sighed, and folded the tissue I offered into a tiny square.
I am accustomed to seeing patients for routine complaints like this. So it is easy for me to forget how scary it is to wonder about mysterious symptoms and imagine the worst.
This is why I’m so concerned when I hear about additional restrictions placed on Medicaid coverage. Access to health care provides us dignity in our vulnerable moments when we are well and sustains us in the rare circumstances when the worst we imagine comes true. And the worst can happen to any of us. I have seen how quickly disease or injury can punish the body, and how completely an addiction can take hold and alter the course of a life. And I have seen how patients like Linda struggle not only to make ends meet, but to get the medical care they need.
Work requirements threaten medical safety net
Most of my patients, including Linda, are on Medicaid. Medicaid is health insurance provided by the government for the most vulnerable among us — the poor, disabled, and elderly. The coverage is not generous, but it is comprehensive. It provides a safety net. Across the country, policymakers are fraying that safety net by imposing work requirements on Medicaid beneficiaries for the first time. Many of these individuals only recently gained health insurance through the Affordable Care Act’s Medicaid expansion. I fear these policy changes will deny the dignity of access to health care to millions of poor adults.
Linda does work, like the majority of able-bodied adults on Medicaid, and she developed the pain in her heel after many long days on her feet. Her employer does not offer health insurance, so she relies instead on Medicaid. Almost 1 in 5 able-bodied adult Medicaid beneficiaries are unable to work outside the home because they are primary caregivers for family members or are attending school. A small portion of the remaining able-bodied Medicaid beneficiaries do not work - and in the majority of cases research shows that they simply cannot find a job.
Precisely how officials will distinguish between these groups — those deemed “deserving” of health care and those deemed “undeserving” — is not clear. Medicaid experts fear that the vague guidance provided by The Centers for Medicare and Medicaid Services will result in vulnerable Americans such as those living in economically depressed communities, those suffering from substance use disorders, and those remaining at home to care for young children or aging parents being deprived of Medicaid coverage because of burdensome documentation requirements and bureaucratic hurdles.
Kentucky, one of the first states to apply for permission from the federal government to erect such barriers to Medicaid, is projecting that construction of the bureaucratic apparatus necessary to process and enforce work requirements will cost US$187 million. Kentucky officials also calculate that the program changes would ultimately lead to savings of $2.4 billion over the ensuing five years, due to individuals dropping off of the Medicaid rolls because they cannot keep up with newly required documentation or simply no longer qualifying for the program.
Legal scholars question whether policies that so nakedly aim to reduce access to benefits are even legal, given that the Medicaid Act calls for all eligible beneficiaries be offered necessary “medical assistance.”
It is clear to me that the primary goal of these work requirements is to further unravel the safety net for the poor and drive eligible individuals off of Medicaid, regardless of the effect on their welfare. The work requirement policies offer no job training to facilitate unemployed individuals a reasonable path to work; and no other state aside from Massachusetts have enacted policies requiring private companies to offer health insurance to their lower income employees, who like Linda, rely on Medicaid. More than anything, for me, it is a return to the pointless and repugnant distinction we Americans continually parse: distinguishing between the deserving and the undeserving poor.
Why Medicaid is crucial
For readers who have private insurance and a steady job, ready access to Medicaid for able-bodied adults may not seem important. But I argue that it is crucial for us all. We are all deserving of health care. Access to Medicaid is crucial for anyone with aging or infirm parents who may decide to stay home and care for them at the end of their lives. Medicaid is crucial for anyone with a friend or loved one swept up in the wave of opiate addiction, which has engulfed more than two million Americans in the last year. Medicaid is crucial for anyone suddenly without income, without savings, and in crisis.
As Linda put her shoe back on and tucked her purse up on her shoulder, she sighed: “I am so glad I came in. I was so worried, because, you never know.”
Linda is right: One doesn’t know. We are all one job loss or one devastating accident away from needing a safety net. What if the worst you can imagine came true for you? What if you were in free fall, ravaged by addiction, broken beyond recognition in an accident, or devastated by a ferocious illness? Wouldn’t you hope that a safety net were hanging there in the depths, ready to catch you? Without Medicaid, there may not be. You may fall through those frayed strings and into the void.
Audrey M Provenzano, General Internist, Instructor of Medicine, Harvard University
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