Most of us believe — rightly so — that government assistance and charity ought to go to those unable to care for themselves, that the able-bodied should work and be self-supporting. The sentiment was embodied in English law in 1563. Justices of the peace were empowered to raise funds for the deserving poor, but those who could work and would not “were to be whipped through the streets, publicly, until they learned the error of their ways.”

Dr. Kenneth Krell

Dr. Kenneth Krell

We still hold those values, and thus 70 percent of Americans in a Kaiser poll support work requirements for Medicaid eligibility for those able to work. Locally, Governor-elect Brad Little, Pro Tem Brent Hill and House Health and Welfare Committee Chairman Fred Wood have all expressed interest in work requirements for those who would qualify for coverage under Medicaid expansion. But recent analysis and publications have cast doubt on the value of such an endeavor.

Previously, an analysis by Kaiser suggested that 6 percent of the 22.3 million Medicaid recipients nationally might be eligible for work requirements. That is, they are not disabled, are not a primary caretaker and are not in school.

Two research letters published this month in JAMA Internal Medicine undertake a detailed, complex analysis of the number of potential enrollees subject to work requirements. The first study finds that 2.8 percent of nationwide enrollees could be subject to disenrollment, accounting for just 0.7 percent of total Medicaid funding. In the six states that have applied for waivers, the affected group represents 3.4 percent of the total Medicaid enrollment group and 1.9 percent of total spending. In the nonexpansion states that have applied for waivers, work requirements would affect only 0.8 percent of enrollees.

More interesting is a second study detailing state-by-state statistics for “Medicaid-eligible persons subject to and not meeting work requirements.” For Idaho, the statistics show 3.4 percent of the total Medicaid population would be subject to work requirements, and that only 0.3-0.4 percent of the eligible population are not meeting those work requirements.

If the Medicaid-eligible Idaho population is 62,000, then only 248 people would be eliminated by work requirements. Which might be OK if it could be done efficiently and without unintended consequences — but it can’t.

Actually, even if it could it’s probably lousy policy. If you want to put that population to work, give them health care. A study in Ohio by their Medicaid office showed that 74.8 percent of unemployed workers found it easier to work by having Medicaid. It’s hard to work if you’re sick.

But the real unintended consequences have to do with costs to the state and the impact by disenrollment of those exempt from the work requirement who fail to meet reporting requirements.

Thirty percent of Medicaid adults report that they never use a computer, 28 percent have no internet access and 41 percent do not use email. Yet the states implementing work requirements have imposed up to monthly work reporting requirements resulting in many more eligible individuals losing coverage than the true slackers.

A Kaiser analysis from June concludes that 62-91 percent of the disenrolled population “remain eligible but lose coverage due to not reporting work activity or exemption.” In Kentucky, a federal judge has blocked implementation of work requirements, stating their waiver application was “inconsistent with Medicaid’s objectives of furnishing medical care.” Cynically, it appears Kentucky had banked on the complexity of reporting requirements to drive people off the rolls and save the state money, eliminating 95,000 from enrollment.

The costs to states to administer the work requirements are staggering and will offset any savings accrued by kicking people off the rolls, and none of those administrative costs can be passed on to the feds. A report by the Center on Budget and Policy Priorities in May stated Kentucky planned to spend $186 million in fiscal year 2018 and $187 million in fiscal 2019 to implement its waiver.

Alaska projects that its proposed work requirements would cost the state $78.8 million over six years, including about $14 million per year in ongoing costs. A Pennsylvania state official testified that a proposed work requirement would cost $600 million and require 300 additional staff to administer. In Minnesota, counties would have to spend an estimated $121 million in 2020 and $163 million in 2021 to implement proposed work requirements.

And in Kentucky, additional costs to the state include fighting the federal order against implementing the work requirements. And in Idaho, you can be sure work requirements instituted by the Legislature will cost the state plenty in court costs. A court challenge will undoubtedly occur since the Proposition 2 wording doesn’t allow for a waiver to be implemented by the state.

When the legislature convenes and starts clamoring for work requirements it’s worth remembering how few Idahoans will be appropriately eliminated, the number of exempt enrollees who will be disenrolled from coverage they deserve, and the actual cost to the state.

Kenneth Krell is an intensivist at Eastern Idaho Regional Center. He can be reached at

Load comments