Medicaid work requirements would violate doctors' oath to 'do no harm' to patients

Just about all of us know someone who is enrolled in the Medicaid program, since it is the single largest publicly funded source of health insurance in the United States, covering one out of every five Americans.

Forty-two percent of them are children, 34 percent are adults, 14 percent are disabled, and 9 percent are seniors.  The program pays health-care costs for almost half of the babies born in the United States, and 62 percent of the cost of care for seniors in nursing homes. Yet if President Trump's administration has its way, millions of our friends, neighbors, co-workers, and relatives, will be at risk of losing Medicaid, and with it, access to needed care.

Breaking more than half a century of established practice, the administration announced that it will start allowing states to require that non-elderly people, who ordinarily would qualify for Medicaid based on their low incomes, to regularly submit paperwork proving that they have a job, are looking for one, or that they are "volunteering" in state-approved community engagement programs.  If they can't submit the required paperwork, they could lose their Medicaid.

Although some limited exceptions would be allowed, such as for people who have disabilities and "medically frail" people, they, too, might be required by a state to submit paperwork to prove they should be exempted, not just once, but periodically to keep their coverage.  So far, the administration has approved Medicaid work requirements in two states, Kentucky and Indiana, and eight others have applications pending for approval by the administration.  Many more are expected to follow.

A top administration official claims that work requirements are "about helping those individuals [able-bodied people] rise out of poverty" by connecting them to jobs or job training.  Actually, the result will be the opposite. A new study from the Center on Budget and Policy Priorities finds state work requirements "will cause many low-income adults to lose health coverage, including people who are working or are unable to work due to mental illness, opioid or other substance use disorders, or serious chronic physical conditions, but who cannot overcome various bureaucratic hurdles to document that they either meet work requirements or qualify for an exemption from them. These coverage losses will not only reduce access to care and worsen health outcomes but also will likely make it more difficult for many people to find or keep a job. Thus, Medicaid work requirements may be self-defeating on their own terms."

The anticipated harm to their patients is why the nation's leading organizations representing more than half a million front-line physicians oppose work requirements. The Philadelphia-based American College of Physicians, the nation's largest physician specialty society, has urged the Centers for Medicare and Medicaid Services and the states to rethink work requirements, observing that "enforcing Medicaid work requirements can introduce more paperwork and impose more barriers to access that would prevent patients from receiving the health care they need …  [imposing] more unnecessary paperwork on patients and their doctors to document that they may be eligible for an exception."  And this comes from an administration that has promised to put Patients Over Paperwork, as it recently proclaimed.

ACP's president, Jack Ende, who teaches and treats patients at the University of Pennsylvania, says that "work requirements could put physicians between a rock and a hard place  — forcing them to choose between following a state's requirement that they document a patient qualifying as 'medically frail' to remain in Medicaid, yet if they are unable to do so, their patients would be harmed by losing their coverage.  Studies show that lack of health insurance is associated with poorer outcomes, including avoidable deaths. Physicians should never be put in the position of participating in a government-mandated process that could harm their patients."

Yet putting doctors in the position of participating in a government-mandated process that is directly contrary to their vow to "first, do no harm" to patients is precisely what the Trump administration and numerous states are encouraging.   Such edicts must be fiercely opposed by physicians, and by anyone who cares about doing no harm to the most vulnerable among us.