This week the Biden administration requested a halt to a Trump-era Supreme Court challenge to state Medicaid work requirements. But how do Americans feel about work requirements for Medicaid recipients? In new research, Simon F. Haeder, Steven Sylvester and Timothy H. Callaghan find that while Americans are split in their support or opposition to Medicaid work requirements, public opinion is more nuanced when the public is asked who should be exempted from these requirements.
In recent decades, the American presidency has experienced seemingly unending growth with policymaking by regulation now frequent. To be sure, Congress sets the broad statutory outlines and has to delegate powers to the executive; but as the Affordable Care Act has shown, modern presidents are well-situated to bend statutory language to favor their preferred policy choices. A highly polarized and hyper-partisan Congress has generally stood by idly, unable or unwilling to counter this growing influence.
At the same time, the courts have eagerly stepped up to fill the void. Most recently, executive actions by the Trump Administration around the Affordable Care Act focusing on short-term health plans and contraceptive coverage have been moving through the justice system. And while most of the public’s focus is on the Supreme Court’s decision about the future of the Affordable Care Act and Roe v. Wade, another crucial issue has wound its way through the lower courts and made it all the way to the Supreme Court’s docket: work requirements for Medicaid beneficiaries, where people are only able to access benefits if they take part in voluntary work or job training. In an about-face from the previous administration, the Biden Justice Department recently asked the Supreme Court to drop the case due to its efforts to disallow any previously approved work requirements.
Using the Trump Administration’s efforts to push requirements for Medicaid beneficiaries as a backdrop, we surveyed Americans on their perceptions about these efforts. Importantly, our analysis expands prior research exploring the neat clear cut division of opposition or support for work requirements in the abstract by disentangling public attitudes on the details of how work requirement programs actually operate.
The Trump Administration and Medicaid Work Requirements
Throughout its tenure, the Trump administration sought to aggressively introduce work requirements into the Medicaid program. It argued that doing so would “put beneficiaries in control with the right incentives to live healthier, independent lives and become more economically secure.” Alongside this argument was the assertion that many beneficiaries have choosing not to work and are therefore improperly benefiting from a program designed for the vulnerable.
This line of argument runs counter to expert consensus, which argues that access to health coverage is vital to supporting the ability of Americans to work. Without sustained access to care, individuals struggle to lead healthy lives and to contribute to the American workforce. Indeed, scholars have argued that taking away medical coverage runs contrary to the goal of alleviating poverty and transitioning Medicaid beneficiaries into stable work environments.
Yet, the Trump Administration was dedicated in their efforts to move forward with plans to add Medicaid work requirements. To do so, it has relied on so-called 1115 demonstration waivers. These waivers allow states to make temporary changes to their Medicaid programs that omit certain statutory requirements. As a result, the Center for Medicare and Medicaid Services has received more than a dozen waiver requests seeking to implement work requirements from states like Kentucky, Arkansas, and Michigan.
Despite growing state interest, efforts to implement work requirements have been stymied by the courts, with only Arkansas’ Medicaid work requirement program being fully implemented. The experience there appears emblematic of many efforts to impose work requirements outside of Medicaid, with thousands of beneficiaries losing coverage simply because they were caught in the administrative jungle of work compliance verification.
Americans are divided on Medicaid work requirements
With growing interest in work requirements formerly from the Trump administration and still from many states, it is important to assess how Americans feel about these requirements for Medicaid beneficiaries, a topic we explored using an original survey we developed and administered to 1,400 Americans.
We started out by asking respondents about their opinions about Medicaid work requirements in the abstract. What we found was unsurprising: when it comes to support or opposition for work requirements in the abstract, Americans are largely split.
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Yet, when we began to dig deeper, important nuances emerged. We specifically asked respondents which groups of beneficiaries should be exempt from work requirements. We found that groups generally considered to be “deserving” by Americans like seniors and the disabled received uniformly high support. We also found support, to a somewhat lesser degree, for pregnant women. On the other end of the spectrum, Americans are largely unwilling to exempt those living in poverty or those dealing with addiction issues from the need to work to obtain Medicaid benefits.
Finally, we queried respondents about whether Medicaid beneficiaries should receive support like assistance with transportation and childcare to facilitate their entrance into the workforce. In contrast to the Trump Administration’s approach, Americans overwhelmingly are in favor of lending beneficiaries a helping hand to make the transition to work easier. Americans are particularly supportive of providing assistance with childcare and transportation as well as job training.
Overall, we found that conservatism serves as an important predictor for support of requiring work as a trade for program eligibility, as do perceptions about the nature of the Medicaid program as a temporary program. On the other hand, opposition to work requirements consistently holds for those with higher levels of political knowledge. Our analysis also showed that perceptions of who deserves what and racial bias continue to shape Americans’ opinions of the Medicaid program itself, as well as its beneficiaries. These findings are in line with the ambiguous legacy of the Medicaid program itself and the provision of public assistance more broadly.
So Where Does This Leave Us?
While lower court judges and the US Court of Appeals for the District of Columbia Circuit have rejected the Trump Administration’s efforts to implement work requirements in the Medicaid program, in December 2020 the Supreme Court announced it would review these decisions at the administration’s request. Then, this week the new Biden administration requested that the challenge be dropped.
Yet, no matter what the outcome of the request, requirements for Medicaid beneficiaries are not off the table. This is because lower courts’ rulings have focused on procedural violations outlined by Administrative Procedure Act (APA) which governs agency decision-making. In particularly, the Trump Administration failed outright in considering the impact on Medicaid’s beneficiaries’ access to medical care, the core objective of the program itself.
This, of course, means that courts have yet to ultimately determine the federal government’s ability to introduce any kind of work requirement into the program. Conceivably, Congress could also strike a grand bargain similar to welfare reform under the Clinton Administration to allow work requirements via statutory language. Yet, given Democratic majorities in both houses, this seems unlikely. Nevertheless, work requirements remain popular with conservative policymakers and with Congressional mid-term elections only 19 short months away, the Democratic hold on power in Washington, DC might be fleeting.
No matter the outcome, our recent work shows that, in the minds of Americans, the role and purpose of the Medicaid program in general and work requirements in particular are far from settled. Indeed, Americans’ views of Medicaid and the populations it serves are complex and continue to be influenced by perceptions of deservingness and race with no consensus in sight.
- This article is based on the paper, ‘Lingering Legacies: Public Attitudes about Medicaid Beneficiaries and Work Requirements’ in the Journal of Health Politics, Policy and Law.
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Note: The post gives the views of its authors, not the position USAPP– American Politics and Policy, nor of the London School of Economics.
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About the authors
Simon F. Haeder – The Pennsylvania State University
Simon F. Haeder is an Assistant Professor of Public Policy in the School of Public Policy at The Pennsylvania State University. He is a Fellow in the Interdisciplinary Research Leaders Program, a national leadership development program supported by the Robert Wood Johnson Foundation to equip teams of researchers and community partners in applying research to solve real community problems. He was also part of the inaugural cohort of the American Enterprise Institute’s Emerging Poverty Scholars program.
Steven Sylvester – Utah Valley University
Steven Sylvester is an Assistant Professor of Public Policy in the Department of History and Policy Science at Utah Valley University. His research emphasizes both public policy and political behavior, with a primary focus on health politics. His research has been published in outlets like American Politics Research, Social Science & Medicine, Political Research Quarterly, and Journal of Health Politics, Policy and Law.
Timothy H. Callaghan – Texas A&M University
Timothy H. Callaghan is an Assistant Professor of health policy and politics in the Department of Health Policy and Management at the Texas A&M University School of Public Health. His research focuses on how politics, policy, and place work together to influence health in America.