March 23, 2016
Countering the Powerful Work Disincentive in Medicaid Expansion
Charles M. Arlinghaus
The New Hampshire state senate is prepared to ignore economic research and abandon any real effort to include a work requirement in its expansion of Medicaid to able-bodied, childless adults. A proposal that began as a supposed compromise would currently abandon the supposed centerpiece of that compromise effort.
New Hampshire’s regular Medicaid has 139,000 enrollees. The effort two years ago to expand Medicaid to the previously ineligible category of childless adults expanded the Medicaid rolls by more than 49,000. As 100% federal funding expires, so does the expansion expire at the end of this year. Supporters of renewing the expansion were able to attract previous opponents by promising to improve the incentives in the program, primarily a work requirement. That promise turned out to be a predictable bait and switch on the part of the sponsors.
Traditional Medicaid applied to categorically eligible populations who could not work — children, the elderly, the disabled. The few times before the ACA that states expanded Medicaid to the population of able-bodied childless adults, they found that having public insurance discouraged work and looking for work. In most cases, a full-time job will raise a worker’s income above the level to qualify for Medicaid so he has a strong incentive not to work full-time.
The most significant natural test of this theory came in Tennessee. Tennessee had expanded Medicaid to childless adults but quickly found it could not afford the costs. In 2005, 170,000 enrollees lost coverage. Academic researchers from Northwestern, Columbia, and Chicago studied the results. The National Bureau of Economic Research summary of the study said “they find an immediate increase in job search behavior and a steady rise in employment and health insurance coverage following the disenrollment.”
NBER’s summary concluded: “The findings suggest there is a powerful work disincentive from public health insurance eligibility.” A similar study by Dague also for NBER similarly found “enrollment into public insurance leads to sizeable and statistically meaningful reductions in employment.”
For New Hampshire’s purposes, these and other similar studies suggest that enrollment of childless adults will reduce job searches and employment for the population we newly cover.
There exists what researchers call a benefit cliff: one additional dollar of income costs the beneficiary thousands of dollars worth of benefits. They behave rationally by staying on the benefit side of that cliff, avoiding full-time employment that would put them over the edge.
To counter-balance that ill-effect, sponsors promised significant and meaningful work requirements of the kind that have made a big difference in welfare programs.
Consider that with meaningful work and job search requirements, our main welfare program called FANF has seen caseloads decline from 13,803 in 2011 in the midst of the recession to just 5,307 last month.
The federal government would prefer we not institute work requirements and has rejected them in other states. But in each of those other states, there was no risk to the feds in rejecting the requirement. The program was not dependent on them. They were just a stand alone wish.
The expansion bill as proposed earlier in the year would have made the program dependent on a work requirement. But sponsors instead imposed a “severability” clause which tells the federal regulators that they can reject our idea with no consequence.
Right now, our plan to “negotiate” with the federal government is to say “I know this is perhaps the last time in modern history you will want something from us but we don’t care. We will do everything you want no matter what. You don’t have to do anything we want. You don’t have to do anything we think is a good idea. But gosh it would be nice if you did.”
I believe the promoters of the expansion plan honestly believe that expansion will create a work disincentive. They also truly believe that a work requirement is good and important. Sadly, though, they don’t want to negotiate for it. They want to give up and not even try.
Making the clause “severable” is the same as neutering it. A more honest approach would be to remove it entirely and dispense with the fiction.
Better policy would be to admit to the “powerful work disincentive” that researchers have found and is just plain common sense. No state before us has gone to the federal government explaining that a work requirement is the only way of addressing one very serious problem with the program and that we simply can’t proceed without one.
Charles Arlinghaus is president of the Josiah Bartlett Center for Public Policy, a free market think tank based in Concord. He can be reached at firstname.lastname@example.org