What The Hell America!

MORE THAN 7 MILLION PEOPLE will become uninsured if Medicaid cuts in Donald Trump’s “big, beautiful bill” become law, according to the Congressional Budget Office. And the single biggest reason for that would be new “work requirements” the legislation would impose on some Medicaid beneficiaries.

The Republicans say they are out to protect taxpayer resources, so that Medicaid isn’t subsidizing people who could be working but aren’t. They also say this is their way of “protecting Medicaid for the vulnerable”—that people who are engaged in productive activity will be able to stay on the program as long as they can prove it.

But one state is trying to do that now. It’s Georgia. And it hasn’t been going well.

Two years ago, the state introduced a similar version of Medicaid work requirements as part of a new initiative called “Pathways to Coverage,” which made Georgia’s Medicaid program available to low-income people who didn’t qualify for the state’s traditionally narrow guidelines.

Tanisha Corporal was one of those people. After being laid off in late 2023 from the social service organization where she had been working, Corporal told me in a phone interview, she split her time between setting up a nonprofit of her own and logging volunteer hours at another organization. It was the type of activity that should have satisfied the Pathways requirement, so she tried and got rejected—three times.

The rejections were electronic, with only a note (which she showed to me) saying “There are no eligible people in your household.” She called and emailed the state benefits office, and went in person too, learning eventually that the glitch on her first application was with her volunteer hours attestation. Evidently, she told me, the letter had too much detail.

She gave up after that, figuring she and her 21-year-old son in college could get by with clinic care until she could buy insurance. Then one day he facetimed from campus, showing her a finger badly bent from a pickup basketball game. He asked if it was ok to go to the hospital, because he knew they were uninsured.

She told him yes, hoping the hospital would work with her later on a payment plan. She also got mad, so when a few weeks later she saw a notice about an open state hearing on the program, she decided to testify by video—describing Pathways as “a nightmare” where “Uploaded forms vanish, calls and emails go unanswered, and administrative office support is nonexistent.”

Her testimony drew the attention of a reporter for the Atlanta Journal-Constitution, who included it in an article about problems with Pathways that Corporal immediately forwarded to a caseworker. The next day, an official from the program called to say they were approving her coverage and making it retroactive to her first application.

The retroactive coverage should take care of her son’s medical bills, Corporal told me, though she said she is still in the process of working out that paperwork with the hospital. But Corporal was left with a lingering fear: How hard would it be for people who, unlike her, don’t have a degree in social work and years of experience navigating state bureaucracies?

“I have a certain level of awareness, aptitude, and ability to advocate, and I’m still getting denied,” Corporal said. “So maybe it’s not just the applicants, maybe it’s the system.”

CORPORAL’S STORY IS JUST ONE DATA POINT, told from her perspective. But it’s a credible story, in part because it sounds so similar to one in a recent article by ProPublica and the Current GA that focused on Luke Seaborn, a classic-car mechanic whom Georgia officials had once held up as proof of Pathways’ success.

Seaborn had signed up right when the program opened, then enthusiastically joined the program’s champion, Republican Gov. Brian Kemp, at a press conference to tout its success. But in the nine months that followed, as Current editor Margaret Coker detailed in her article, the system kicked Seaborn off of the program twice because of paperwork issues—even though, like Corporal, he said he’d followed all the programs instructions and rules.

“I am so frustrated with this whole journey,” said Seaborn, whose enrollment the state reinstated following Coker’s inquiries to state officials. “I’m grateful for coverage. But what I don’t understand is them leaving me like a mushroom in the dark and feeding me nothing, no information, for more than a month.”

“I used to think of Pathways as a blessing,” he said. “Now I’m done with it.”

Stories like Corporal’s and Seaborn’s go a long way to explaining why Pathways has turned out the way it has. Initial state projections suggested between 31,000 and 100,000 residents would sign up during its first year. Fewer than 5,000 actually did. And in more than 40 percent of Georgia counties, less than ten—that’s ten people, not ten percent—had enrolled after year one.

Lack of awareness is probably a factor in the low enrollment: Lots of eligible people have no idea the new program exists. But two independent assessments—one by a state contractor, one by an independent research organization called the Georgia Budget and Policy Institute—found that a bigger obstacle were the kind of paperwork issues that bedeviled Corporal and Seaborn, and that can be even tougher for the people who need Medicaid the most.

“They may not have access to consistent internet, their phone number may not be active if they’re not able to pay their bill that month,” Leah Chan, a researcher at the Georgia Budget and Policy Institute who conducted that organization’s assessment. “They may be moving a lot because of the high cost of rent and low housing stock. So there’s a lot of issues that can make it more challenging.”

Nothing about Georgia’s experience should have been surprising, because pretty much the same thing happened in 2018 when Arkansas introduced work requirements—not for a new group it was trying to enroll, as Georgia did, but for people already on the program. More than 18,000 beneficiaries lost coverage over a span of ten months, as the state systematically purged people who had not made it through the verification process.

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Harvard researchers examining the data later estimated that more than 95 percent of the target population actually satisfied the Arkansas work requirements, meaning they were not just eligible but legally entitled to coverage. Behind those numbers were befuddled applicants who couldn’t make their way through the verification process or got rejected for unexpected reasons, ending up uninsured and, in some cases, stuck with medical bills they couldn’t pay.

A federal judge in early 2019 put a stop to the Arkansas program, on the theory that the effects were incompatible with Medicaid’s basic purpose of promoting health care access for the poor. That legal rationale would disappear under the new Republican bill, which would not merely permit work requirements but make them mandatory.

In other words, Medicaid in every state would look more like it did in Arkansas before the court order, and more like it does in Georgia today.

SUPPORTERS OF THE GOP BILL SAY that coverage losses will be a lot smaller than the CBO and other analysts have predicted—and that, to the extent people lose insurance, it will simply be the able-bodied who should be working.

As proof, they cite a number of provisions in the bill they say are designed to avoid precisely the sorts of problems that have cropped up before. Among other things, the GOP bill provides states with money to upgrade their data systems, to make them more responsive and less error-prone. It also includes a long list of exemption activities—like caregiving—that Georgia’s program doesn’t have.

But while the Republican bill would apply work requirements only to those people with incomes above the poverty line who are part of the “expansion” population—meaning those states that made Medicaid more widely available after 2010, using extra funding from the Affordable Care Act—it would include everybody in that group up to age 65. An earlier version of the bill stopped at age 55, on the theory that low-income people older than 55 tend to have a harder time finding work, and are more likely to have infirmities making work more difficult. But by bumping up the age they produced bigger budget savings, though more people are losing coverage.

The extra money the bill would allocate to data systems should help, although the effects will depend a bit on how much time states have to implement the changes. Conservative Republicans have pushed to move up the date at which work requirements kick in from January 2029 to January 2027.

“A tight timeline for implementation of Medicaid work requirements could mean fewer systems are in place to automatically verify people’s work status, and the outreach to inform enrollees of their reporting responsibilities may not have ramped up,” Larry Levitt, senior vice president at the health research organization KFF, told me. “That could mean even more people slip through the cracks and end up uninsured.”

But advocates and experts say a bigger factor is the difficulty so many Medicaid beneficiaries have documenting their status—especially because, Georgetown Research Professor Leonardo Cuello told me, the current legislation includes a “look back” provision allowing states to disqualify applicants who haven’t maintained the minimum hours for a month or two or even six or twelve prior to applying.

“One of the groups of losers from work requirements are workers,” said Cuello, who in his previous position at the National Health Law Program frequently spoke with Medicaid applicants and beneficiaries while researching policy or preparing litigation.

“They often have informal employment arrangements—they don’t have pay stubs they can show you, maybe they’re doing work in their neighborhoods,” he went on to explain. “You have a lot of people who are low-wage shift workers, who cannot control their hours. They wish they could be guaranteed a reliable, steady income. But every month, they find out from their employer how many shifts they’re going to get. And, you know, income just changes every month based on that.”

DEANNA WILLIAMS, A “NAVIGATOR” with Georgians for a Healthy Future who helps residents enroll in public health programs, told me she has seen this first-hand: “There are a lot of people who apply for the program who [worry] about meeting those hours because they have service jobs. If they are working at a restaurant, where their hours may fluctuate, or they are working in retail—during the holidays you may get more hours than normal, but during the regular season you don’t get that many hours.”

And then there are questions about the exemptions—which, in theory, are there for those “vulnerable” populations that Republicans on Capitol Hill keep saying they want to protect.

In practice, advocates and analysts told me, documenting care for somebody other than a child, or demonstrating a disability making it impossible to work can prove difficult for a population in which people are more likely to have poor access to and knowledge of technology, not to mention inconsistent or unreliable housing and phone service.

A lot would ultimately depend on exactly how states interpreted the mandate to impose work requirements—and how carefully they applied them. But even a state committed to promoting health coverage and reaching the vulnerable could find it difficult.

Just ask Robert Gordon, a veteran of New York City government and the Obama administration. In 2019, Michigan Democratic governor Gretchen Whitmer tapped him to run the state’s department of health and human services, and one of his biggest jobs was implementing a work requirement Michigan Republicans had enacted years before.

The state invested heavily in data systems, call centers, and outreach, as part of a broader effort to streamline public services. Even so, the best estimates suggested that more than one in seven Medicaid beneficiaries in the state—more than 100,000 Michiganders—would lose Medicaid in the process.

It never happened because of a court ruling similar to the one that shut down the Arkansas experiment. But to Gordon, it was proof that the expense, difficulty, and collateral damage of imposing work requirements are simply not an effective use of state resources—and that, as he wrote in a recent Commonwealth Fund paper, “the Americans who lose insurance through no fault of their own will suffer the most.”

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THE DEBATE ABOUT WORK REQUIREMENTS isn’t all about practicality. It’s also about morality—about who deserves help and who doesn’t, and what obligations society as a whole has to each of its members, including those who for whatever reason need more help along the path of life.

That debate has been playing out in American politics since at least the mid-1970s, when Ronald Reagan introduced the “welfare queen” concept, and led to major policy changes in the late 1990s, when Bill Clinton signed a landmark and controversial welfare reform law linking cash benefits to work status.

Arguments over that law’s impact—how it affected poverty, what it has meant for children, and whether it really promoted work as promsied—continue to this day. But even many of those who consider the ’90s transformation a model of success have questioned whether work requirements are such a good idea for health care.

One reason is that health insurance isn’t a cash benefit: “There’s no Medicaid member in the state of Georgia that gets a check for Medicaid,” Laura Colbert, executive director of Georgians for a Healthy Future, told me. “All they get is health coverage, which doesn’t pay your rent, doesn’t get you groceries, and doesn’t get you to and from work.”

In other words, the “welfare queen” stereotype doesn’t quite fit when one of the only things you can buy with a benefit is an extra colonoscopy. And it doesn’t show in the data either.

Repeated studies have found no evidence that linking Medicaid to work affects employment levels, in part because most people on Medicaid already work or have a reason (like caregiving responsibilities or a disability) why they can’t. Overall, able-bodied people who don’t fall into one of those categories account for just 6 percent of the working-age Medicaid population—and 3 percent of the total—as Matt Bruenig of the People’s Policy Project noted in a recent New York Times opinion article.

“People get kicked off, often people who were playing by the rules but lose coverage because of bureaucratic error, in droves,” Luke Shaefer, a professor and poverty researcher at the University of Michigan, told me over email. “But there is very little evidence that [a work requirement] increases work, in large part because most low income families are already working and those that are not largely can’t.”

As it happens, there is some evidence that giving people health insurance can put them in a better position to get and keep a job, because they are more likely to stay in good health. And that’s just one of the reasons proponents of universal health care believe the government should make sure everybody has insurance, regardless of economic circumstance or work status. They see broad Medicaid eligibility as part of a strategy to achieve that.

This is not a consensus position in American politics. A big reason Republicans are trying to downsize and limit Medicaid is that they believe health care should be primarily a private responsibility, with the government stepping in only for people in serious need—and even then, only carefully and with strict controls on who can or can’t get the help.

You can argue for or against that proposition. But it’s worth paying attention to what else is happening right now. The Republicans imposing such an onerous, unforgiving enrollment process on poor people are the same ones clearing regulatory burdens for corporations and dialing back enforcement of high-income tax fliers.

These are also the same Republicans who, while taking hundreds of billions out of public health insurance programs for low income Americans, are trying to extend trillions in tax cuts that skew heavily towards the wealthy—which suggests maybe their real motive isn’t to improve or save Medicaid, but to divert its funding for a purpose and group of people they consider more important.