Work requirements for Medicaid? Boring; here's something more impactful
Let's actually help people on Medicaid by breaking the program's main addiction
About 25 years ago, I was asked to sit on a panel during a meeting of the Idaho Association of Commerce and Industry, back when the organization wasn’t controlled by big businesses. I don’t remember what the panel was about but I do remember a lobbyist bending my ear for a few minutes.
“You should talk about the need to address Medicaid spending,” she said, to which I agreed. I was just a young state government reporter, and to be honest, I didn’t fully understand Medicaid, the state-federal medical welfare program for the poor and disabled. But I did understand the conversations around the issue. The state of Idaho’s spending in this category was just north of $600 million, of which $171 million came from the state government, the rest coming from Washington, D.C. The state had just addressed a $26 million shortfall. Medical welfare spending was already on the rise, and the forecast to contain costs wasn’t that great. Something needed to be done, and quickly.
To say my pitch had no impact is an understatement. More than two decades later, Medicaid is bigger — it now includes childless, able-bodied adults — and much more expensive. The program costs $4.7 billion in the current fiscal year and the Department of Health and Welfare has requested $5.3 billion for the fiscal year that starts July 2025. Of that, $1.8 billion would come from state taxpayers. Medical welfare is the biggest program in all of state government, exceeding education spending by about $300 million.
Lawmakers finally did some fretting about medical welfare spending in 2023, only to follow up their handwringing with a decision to expand Medicaid beyond what voters authorized 2018.
So now, there’s some talk that maybe come January, when the Legislature meets again, things will be different. It’s expected that the House and Senate will be more conservative than ever in the state’s history. So lawmakers are talking about instituting reforms to the program, such as requiring people to work to get benefits.
I used to be OK with work requirements, but not any more. Government never administers work requirements to much usefulness or consistency. Sometimes, a work requirement isn’t work at all, e.g., putting in time volunteering at the local animal shelter sometimes counts. I’m not sure what is proven by spending an hour petting cats.
Typically, politicians will write a work requirement that exempts more people than it covers. This allows lawmakers to tell their voters they've implemented work requirements when really only a fraction of eligible welfare recipients are ever covered by it. It's a bit of a con game, really.
The problem with medical welfare isn’t lack of work requirements. The problem is what Medicaid does to the human condition. There’s nothing particularly healthy about a system that separates the needy from people and organizations in a community that are willing to help.
Prior to the rise of the welfare state in the 1930s and 1960s, that’s what Americans did. They cared for one another. They offered assistance to those who needed it. Neighbors were invested in the health and wellbeing of neighbors, and that system provided for natural reciprocity. Later, if the giver was ever in need, their past charity was rewarded with the kindness of others. This is a natural part of our humanity, which we’ve now outsourced to government programs.
If Idaho lawmakers really want to do something impactful, repeal the stinkin’ medical welfare program in its entirety. There is nothing in law that requires the state of Idaho to participate in Medicaid. Every state in the country does, but it is completely unnecessary and has undermined the healthcare systems of every state and every community, the extent to which is a topic for another day.
But I’m sure that idea of repealing Medicaid won’t make it out of a single committee, and probably wouldn’t even come up for a vote of any kind.
So I offer the next best thing: Repeal the pharmaceutical coverage, which is also an optional part of Medicaid. States are not required to offer it.
When lawmakers talk about Medicaid, they look at dollars, utilization costs, and population growth. They don’t look at the raw human toll of a system that provides people a steady supply of free medications. This is, in no small part, perpetuating the mental health crisis in America in ways that are not very well understood. What I can say, however, is that there is plenty of evidence that depression, anxiety, PTSD, ADHD, and other mental health conditions would not exist at the levels that they do but not for the availability of government-covered prescription drugs.
Adding work requirements isn’t a bold idea. It’s a boring one. Lawmakers should do something meaningful: Look beyond the dollar signs and see how the existing system maintains the suffering of our friends, family, and neighbors. They’re addicted to the pills, addicted to the program. Repeal the pharmaceutical benefit.