Work requirements are Republicans’ preferred delay tactic for Medicaid expansion

Republicans are making Medicaid expansion conditional, leaving thousands at risk.

Medicaid rally on 2/08/18
Credit: Sarah Gunter
Medicaid rally on 2/08/18 Credit: Sarah Gunter

A lot has changed since Virginia’s gubernatorial race last November yielded the highest voter turnout in 20 years. Then, health care moved people to the polls, as casting ballots at the time meant extending health care to 400,000 people. Despite historic Democrat gains, Republicans maintained control of the state house. Now, Medicaid expansion is subject to unprecedented conditions.

The Affordable Care Act (ACA) sought to expand Medicaid eligibility to people making up to 133 percent of the federal poverty level nationwide, but a 2012 Supreme Court decision ruled that this was unconstitutionally coercive of states, making Medicaid expansion optional.

Today, Virginia, which has a 51 to 49 Republican majority in the House, is one of 18 states that has not expanded Medicaid. Advocates there and in a half-dozen more states are trying to change that in 2018. With the Trump administration recently approving Kentucky’s Medicaid work rules, conservative lawmakers in non-expansion states hope to follow suit, saying they’ll only give in to expansion if work requirements are part of the package. This conditional support is leaving advocates — who, in Virginia, helped galvanize enough voters for Democrats to pick up 15 seats — feeling wary.

VIRGINIA ORGANIZING Medicaid rally on 2/08/18

Thousands of people in states that have opted out of expansion have fallen into a “coverage gap,” which refers to uninsured people who make too much to qualify for Medicaid but too little to meet the minimum income requirement for subsidized insurance on the Obamacare exchanges. In Virginia, about 400,000 people fall into this coverage gap, adding to the urgency of the fight for Medicaid expansion in 2018.


“We are going to keep being the force pushing for straight expansion,” said Virginia Organizing’s Brian Johns. “Let’s not bargain with ourselves.” Johns’ group held the first of 12 Medicaid expansion rallies last Thursday evening; his group and a handful of others are continuing to apply pressure this legislative session.

“If your position is to pass straightforward Medicaid expansion without work requirements or other reforms, then you will be responsible for the failure to provide health care coverage to more Virginians,” said Speaker of the House Kirk Cox (R) in a letter to Gov. Ralph Northam (D). Cox said his House Republican caucus will only support Medicaid expansion if Democrats agree to impose work requirements on the current Medicaid population. While the Democratic Caucus is pleased that Republicans are open to talking about Medicaid expansion this session, they aren’t happy with the conditions. Adding work rules or any other restriction could trip consumers, and also the governor’s office says administrating the requirement will cost $10.5 million in the first year.

Lawmakers have until February 18 to decide whether they’ll tackle Medicaid this session; that’s when the legislature will release its budget, which could set aside money for the project. Activists are demanding lawmakers pass a straightforward expansion bill, with no strings attached, as “this conversation around work requirements is yet another way to stigmatize and demonize people who are trying to make ends meet,” said Anna Scholl of Progressive Virginia. “[There’s] nothing fundamentally wrong or immoral with being poor,” she said. This is why work rules are a nonstarter.

“I think Republicans suffered historic loses last November and they were seen as the party to keep people from getting health care,” said David Broder, president of a 3,000-member union of home care providers. Many of these providers fall into Virginia’s coverage gap, so he mobilized them to vote in the last election. “If that’s the path that goes down [this legislative session], they’ll see the same thing in 2018 and 2019 and so forth.” Republicans only kept control of the legislature by a coin toss.


State laws dictate the means by which a state can expand Medicaid. To do so, voters need to stay mobilized. The last state to expand Medicaid was Maine. Residents were only able to expand Medicaid after winning a ballot initiative, as the governor was not supportive of expansion. Before Maine, was Louisiana, which was able to expand Medicaid only because a supportive Democratic governor was elected; and he signed the order on his second day in office. Advocates are encouraged by these efforts, including those in Utah, where they are seeking to bypass the state legislature to expand Medicaid.

“Look at Maine — I think you are going to see the same thing in Utah,” said Utah Decides Healthcare‘s RyLee Curtis. “You are going to see the political will of the people.”  

While Utah Republican lawmakers push legislation that expands Medicaid and imposes work rules, activists are trying to push a straightforward Medicaid expansion. Roughly 100,000 residents fell into a coverage gap.

Credit: Utah Decides
Credit: Utah Decides

Lawmakers are on “a tighter deadline than we are,” said Stacey Sanford of the Utah Health Policy Project, another group advocating for a straightforward expansion. “The initiative has thought of everything whereas these legislative routes don’t even have text yet.”  

The Utah state representative who’s leading the efforts, Robert M. Spendlove (R), has until March 8 to introduce and pass his conservative Medicaid expansion bill, as that’s when the legislative session ends. Utah Decides Healthcare has until April 15 to collect 113,000 signatures to put a straightforward Medicaid expansion on the ballot next November, and so far, they are on track to meet the goal. The ballot initiative is written to supercede any kind of work requirement, said Sanford.

Concessions in health policy are always part of the equation. In fact, the ACA in and of itself is largely seen by progressives as a compromise to single-payer health care. But most activists who spoke with ThinkProgress do not think Democrats should concede to delay tactics yet, especially because Medicaid expansion is very popular. Most activists wouldn’t even entertain the choice of Medicaid expansion with work rules or nothing at all. When Virginia Gov. Ralph Northam tempered his support for Medicaid expansion in an interview, voters reminded him that they elected him last November; he’s since changed his tone. A majority of Virginia voters have supported expansion since 2014. The Utah legislature tried to pass expansion in 2016, as it’s also popular there.


Moreover, adding red tape will likely lead to coverage loss, which is the antithesis to Medicaid expansion. In Indiana, when state lawmakers expanded Medicaid, they imposed premiums onto poor people and dropped them if they failed to pay in time. Roughly 71,000 people lost or were prevented from enrolling because of the restrictive policy.

Even so, for some in Indiana, the way the state expanded Medicaid beats the alternative. “If we are asking if the state did better off than having no expansion, then pretty clearly the answer is yes,” Kosali Simon, an economist at Indiana University, told Kaiser Health News.

Families USA Senior Director of Campaigns, Outreach and Engagement Patrick Willard sees this narrative — that states could only expand Medicaid if they impose work requirements — as a false choice. Health care doesn’t need to be conditional because it shouldn’t be a privilege.

“People are making political arguments and trying to create this notion that health care should be a privilege for people and that we should only be providing health care as a reward to people, rather than understanding that we actually need to provide health care to people so that they can work and so that they can take care of their families,” he said.

“I think it is a political argument that is going to run into the fact that it is not allowed by the law,” he added. In fact, three organizations filed a lawsuit last month arguing just that.