Support for Work Requirements but Opposition to Terminating Benefits Among Medicaid Enrollees and NonEnrollees in Kentucky: Results from a Statewide Survey

Abstract

More than a dozen states have sought federal approval for Section 1115 Medicaid waivers to make premiums and work requirements (ie, requirements to work, volunteer, or engage in education, or caretaking), a condition of Medicaid eligibility for adults deemed able‐bodied. Support for these waivers may differ among adults based on Medicaid participation and political affiliation. We report results from an original 2019 survey of a representative sample of adults in the Commonwealth of Kentucky investigating attitudes regarding work requirements, mandatory premiums, and program exclusions as penalties for noncompliance. We conducted a statewide survey of N = 1203 adults in Kentucky; 601 participants were contacted by phone via random digit dialing and 602 contacted as part of a standing web‐based panel of Kentucky residents. At the time, Kentucky had an approved Section 1115 waiver to establish work requirements and premiums for adults considered able‐bodied. The sample was representative of Kentucky adult population on the basis of age, gender, race/ethnicity, phone use, poverty level, internet access, and geographic region. A majority of Kentuckians (69%) supported the concept of work requirements, agreeing that “If people are able, they should be required to spend time volunteering or working to stay on Medicaid.” Support was higher among nonenrollees (73%) than Medicaid enrollees (64%). But only 43% of the general population, 48% of nonenrollees, and 36% of enrollees agreed that people who do not meet their hours “should lose their Medicaid benefits.” More than half of respondents proposed work hour thresholds that were lower than the 20 hours a week proposed by most states. Among Medicaid enrollees, support for work requirements was higher among those who were employed (versus unemployed), but there was little difference by political party. Opposition to mandatory premiums was high; only 34% of the general population, 38% of nonenrollees, and 28% of enrollees agreed that “People should be required to pay some money out of pocket each month to have Medicaid.” Among people enrolled in Medicaid, support for mandatory premiums was lower among people who were unemployed, and among Democrats compared to Republicans. Only 22% of the general population, 23% of nonenrollees, and 20% of enrollees supported the termination of benefits for people who miss premium payments. The majority of adult Kentucky residents support policies that require Medicaid beneficiaries to work or volunteer. However, a majority also oppose penalties that terminate benefits for people who do not comply. A majority disagreed with mandatory premiums in Medicaid, including program exclusion penalties for premium nonpayment. Work requirements in Medicaid are largely halted due to legal challenges and have been discontinued by executive order in Kentucky. If work requirements and premiums take effect elsewhere, policy makers and researchers should consider how enrollees’ beliefs may affect the acceptability and perceived legitimacy of Medicaid waiver...

How difficult should it be? Evidence of burden tolerance from a nationally representative sample

“…The public also does not fully understand the consequences of work requirements, or at least support the most extreme consequences. Underhill et al ( 2020 ) find people were generally supportive of work requirements for Medicaid, but oppose removing Medicaid if clients do not satisfy these requirements, and proposed lower hour thresholds than was typical of policymakers. In short, people like the idea of a stick, but not actually using it.…”

“…Such a relationship is consistent with a simple incentive account, where people seek to minimize costs. Prior work shows that family experience of burdens in welfare policies also reduces tolerance for these burdens (Pereira and Van Ryzin 1998 ), and that Medicaid enrollees tend to be less supportive of work requirements in Medicaid (Underhill et al 2020 ).…”

“…1 Second, such burdens can have large effects. The one state that implemented the new Medicaid work requirements for a sustained period of time saw a significant decline in participation, driven by people who were actually working or should have been exempt from the requirement (Sommers et al 2019 ). The work requirement therefore excluded people who struggled with the reporting aspects of the process, rather than distinguishing those who were truly eligible from those who were not.…”