When Congress passed President Trump’s signature domestic policy bill last month, they voted to take health care coverage away from about 10 million people. In the past, And they openly boasted about part of it.
About half of the 10 million will lose coverage because of a new requirement that people who enroll in Medicaid prove that they are working, looking for work or unable to work. Funds generated will be used to finance tax cuts for the wealthy.
Republicans have put more stock in an idea that has long been a part of the American conversation about health insurance: that it is a benefit one earns by working. Work requirements have overwhelming support among Republicans, and polls have found that about half of Democrats back the idea, too.
Democrats have warned that some people who do work will lose Medicaid because they can’t file the right paperwork.
The United States’ large uninsured population has forced the creation of a vast, ad hoc safety net that fills the gaps in a patchwork system.
In the years following World War II, most of the United States’ peer countries were creating universal health coverage. Each put its own spin on the idea. Britain made doctors government employees when it built its National Health System in 1948. Canada’s coverage scheme relied on public insurance that paid private doctors for care. Australia came up with a two-tier system: basic public insurance for everybody, with the option to buy a private plan for more generous benefits.
The United States took a completely different path: It tied insurance to employment. American companies facing labor shortages began courting workers by offering them health benefits. Employers were under wartime wage controls but insurance coverage didn’t count, making it an attractive way to provide additional compensation.
In 1954, the Internal Revenue Service gave employer-sponsored insurance an even bigger boost when it made health benefits tax-exempt.
After years of debate, Medicare and Medicaid started in 1966. Medicare was a straightforward program that covered all adults over 65. Medicaid was more complicated. It gave the coverage only to those already receiving cash assistance because they had conditions excluding them from employment. At the time, this included the blind, people with disabilities and single women with children.
Obamacare passed in 2010, expanded Medicaid to anyone who earned less than 133 percent of the federal poverty line. They refashioned Medicaid to look more like Medicare, a program that covers everybody who meets a single condition.
But Medicaid only rarely charges deductibles or co-payments, whereas the average employer plan now has a nearly $2,000 deductible before it kicks in.
A few years after Obamacare passed, several Republican states began proposing adding a work requirement to the program. Somebody who is able-bodied and receiving a public benefit, they ought to have a responsibility, they said.
Their supporters were elevating the idea that people won’t face much harm if they lose medical coverage.
Newer research that uses bigger data sets has started to find that insurance coverage, and Medicaid in particular, does lower death rates. The connection is strongest when researchers look at older, sicker populations.
There is also the financial and mental strain of lacking coverage, which can affect a person’s well-being but wouldn’t turn up in a study that strictly measured physical health outcomes. In my 15 years covering America’s health system, Uninsured patients are too scared to go to the doctor because they fear a large bill on the other end.
Another problem: emergency rooms refusing to see patients who did not have the means to pay. This led to the Emergency Medical Treatment and Labor Act, which requires emergency rooms to provide “life-stabilizing” treatment to everyone, even the uninsured.
Uninsured Americans may be scraping together the care they need from free clinics and emergency rooms but they may be doing so at great personal cost, arranging child care for a long wait or having their paycheck garnished when they can’t pay the medical bill.
With some 10 million people expected to lose their access to Medicaid in the decade after the domestic policy bill goes into effect in 2027, more patches may soon be needed in the system.
The Medicaid work requirements in the bill do not take effect until 2027 and, at the last minute, the Senate added a waiver provision that could push the policy back until 2029.
