What The Hell America!

Congressional Republicans are poised to make massive spending cuts to the Medicaid program that provides health insurance to millions of Americans — in part by enacting federal work requirements that they claim won’t affect the most vulnerable recipients. But data analysis shows that poor middle-aged and older women would be among the most impacted.

Republicans have repeatedly said that mandating work requirements is aimed at able-bodied adults without dependents, or “capable adults who choose not to work,” as Rep. Brett Guthrie of Kentucky, a key Republican budget policymaker, described it in a recent op-ed in the Wall Street Journal.

House lawmakers are trying to advance a budget reconciliation bill that would cut about $715 billion over 10 years from the Medicaid program, the federal-state health insurance program for nearly 80 million Americans, including caregivers, children and people with disabilities. The effort is tied to President Donald Trump’s policy priority of extending tax cuts that benefit wealthy people the most. 

The nonpartisan Congressional Budget Office estimates at least 13.7 million people altogether would become uninsured if the current legislation is approved, including at least 7.7 million people impacted by the changes to Medicaid and the Affordable Care Act (ACA). The bill does not extend enhanced premium tax credits for ACA coverage that are set to expire at the end of the year, also potentially raising the cost of insurance for millions of people.

House Speaker Mike Johnson is trying to get the full House to pass “one big, beautiful bill,” as Trump has described it, before the end of this month, in part by making Medicaid recipients ages 19-64 prove they’re working 80 hours a month, described in the legislation as “community engagement.” There are exemptions to the requirement, including if someone has a disability or is a caregiver — but congressional Democrats and health advocates have warned those people risked coverage loss if they need to show frequent proof of that exemption.

Sixty-four percent of adult Medicaid recipients under 65 years old are working either full-time or part-time. Others do not hold traditional jobs but participate in some form of work — either through caregiving responsibilities (12 percent) or school attendance (7 percent). Another portion (10 percent) have an illness or disability, according to KFF, a health policy research nonprofit.

That leaves about 8 percent of Medicaid recipients who are not working for another mix of reasons: retirement, inability to find work or some other unnamed reason in the available data.

Within this group, most — four in five, or nearly 80 percent — are women, according to nonpartisan researchers at the University of Massachusetts Boston, who recently analyzed Census Bureau data from the 2023 American Community Survey (ACS) to reach their conclusion. The survey is a well-known standard in annual population data, with information collected from more than 3.5 million households.

“We’re using U.S. Census data, and we’re linking that source, and we’re giving you all the details of exactly what we looked at so that you can replicate it,” said Jane Tavares, a senior research fellow at the LeadingAge LTSS Center at UMass Boston. “I think that’s a really important thing to consider when you’re looking at some of these narratives or some of these opinion pieces — are they doing the same thing?”

Key Republicans have claimed there are enough “young” and “able-bodied” men on Medicaid that coverage should be contingent on them working or engaging in an approved activity.

“No one has talked about cutting one benefit in Medicaid to anyone who’s duly owed. What we’ve talked about is returning work requirements,” Johnson told reporters in early April. “So for example, you don’t have able-bodied young men on a program that’s designed for single mothers and the elderly and disabled. They’re draining resources from people who are actually due that. So if you clean that up and shore it up, you save a lot of money, and you return the dignity of work to young men who need to be out working instead of playing video games all day.”

On Wednesday, Health and Human Services Secretary Robert F. Kennedy Jr., along with the heads of federal agencies and divisions that oversee government assistance programs that help low-income people, penned an op-ed in the New York Times where they defended work requirements on not just Medicaid but also the Supplemental Nutrition Assistance Program, known as food stamps, among others.

“For able-bodied adults, welfare should be a short-term hand-up, not a lifetime handout,” said the authors. 

The data shows Medicaid recipients who are in this smaller group of able-bodied recipients are primarily women who are, on average, 41 years old. A quarter are over 50. Most have a high school education or less. They are also poor: Their median income is zero, and their average household of 4.4 people has an annual median income of less than $45,000.

They were also recently part of the workforce, with just over half (56.2 percent) having worked within the past five years. Upwards of one-third are looking for work. Some may have left the workforce to care for family: either elderly parents or adult children or spouses with disabilities — or a combination.

“This is really an attack on formally caregiving, older women who have a very hard time getting back into the workforce — not young men who are able bodied and sitting around because they don’t feel like working,” said Alison Barkoff, a health policy professor and program director at the George Washington University Milken Institute School of Public Health, who also wrote about the analysis from UMass researchers.

Republicans who support the bill, some of whom represent districts with large percentages of Medicaid recipients, claim vulnerable populations will not be impacted by the funding cuts — going so far as to criticize the media for how it’s reporting on the bill, and disability advocates and Medicaid recipients who attended a marathon committee meeting that began Tuesday over the provisions.

“Here’s my apology to you: I am sorry that people lie to you, I am sorry that so many people in the media and on the left have lied to you about what’s in this bill,” said Rep. Dan Crenshaw, a Republican from Texas, during the meeting. Republicans ultimately advanced the legislation Wednesday on a party-line vote.

At least two dozen attendees, including people in wheelchairs, were arrested Tuesday amid protests that mirrored efforts in 2017 to protect the Affordable Care Act. Medicaid in particular is a highly popular program among people of all major political leanings. That might be why, some policy experts have noted, the work requirements would go into effect in 2029, after the next presidential election.

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Amid advocates’ concerns: Work requirements will extend beyond the 8 percent targeted by Republicans because policymakers with state-level work requirement policies have mandated that recipients file frequent paperwork to prove their exemption.

That tends to kick people off the program, according to Andrea Ducas, vice president of health policy at the liberal Center for American Progress. In Arkansas, a work requirement has been linked to more than 18,000 getting disenrolled from Medicaid. In Georgia, a work requirement program led to high administrative costs and fewer eligible Medicaid recipients enrolled than expected.

“We know from previous state experiences with implementing work requirements that they primarily work by kicking eligible people off of coverage,” said Ducas, who has researched the effects of potential work requirements on children. “It’s very, very hard for people to make it through the red tape to either prove that they’re working or that they qualify for an exemption.”

Gelila Selassie, senior attorney for the advocacy organization Justice in Aging, agreed.
“This has nothing to do with getting people to work,” she said, noting available data. “These people — especially women — are either working or caregiving or in school or are disabled. So the only way for them to meet these $800 billion in cuts is by taking away health care from eligible people, because there’s just not enough ineligible people to meet those demands that they’re supposed to cut.”