Kentucky is one of the poorest states in America, and its residents are among the sickest. Yet the governor's decision to force Medicaid recipients to meet a work requirement — something that could take health coverage away from 100,000 people — is unlikely to carry any political repercussions for the GOP in this deeply red state.
Democrats, with their eyes on the 2018 congressional elections and 2020 after that, are taking notes on every move Republicans make that reduces access to services for the poor. But in Kentucky, political operatives think the left will be disappointed.
“If you can say, 'All we’re doing is requiring people to be more active participants in their health care and require some work-related activities,' I think the general population looks at that and says, ‘What’s the matter with that?”’ said Al Cross, editor and publisher of Kentucky Health News and a former state political reporter for the Louisville Courier Journal.
"In this state and lots of low-income states, there's a strong level of resentment," Cross said, for people who get government-subsidized health care while those who work often struggle to pay for it.
On Jan. 12, Kentucky became the first state to get federal permission to suspend Medicaid coverage for "able-bodied" adults who don't complete 80 hours per month of community engagement activities," like employment, education, job-skills training and community service.
A Kaiser Family Foundation poll from 2017 found that 70 percent of the public supports work requirements for Medicaid recipients, and Kentucky’s GOP governor is betting his residents feel the same way.
"We are ready to show America how this can and will be done," Gov. Matt Bevin told reporters at the state capital in Frankfort, on Friday. "And many other states will follow. It will soon become the standard and the norm in the United States of America. And America will be better for it."
Supporters say the Medicaid work policy will cut government dependency, weed out people who don’t really need the assistance and build work ethic among low-income enrollees. Critics say the requirement will be expensive to administer, provide an unnecessary barrier to coverage and penalize people who can’t work due to undiagnosed medical problems. In Kentucky, for instance, the new restrictions are projected to cause nearly 100,000 people to lose Medicaid coverage, according to the Kentucky Center for Economic Policy, which studies how state policies affect working-class families.
Nevertheless, eight other states with Republican governors, including Indiana, Kansas, Arkansas and Wisconsin, have asked the Trump administration for authority to enact similar requirements, according to the Kaiser Family Foundation. Mississippi has also asked to allow work requirements, but their waiver proposal hasn’t been certified as complete, Kaiser reported. Under Democratic Gov. Roy Cooper, North Carolina has also sought permission for work requirements, but only if the state expands eligibility for Medicaid.
Several of the states mulling a Medicaid work requirement are expected to be battlegrounds for statewide and congressional elections in November.
In Indiana, Sen. Joe Donnelly, a Democrat, will defend his seat in 2018. In Kansas, Republican Lt. Gov. Jeff Colyer and Secretary of State Kris Kobach, are among 13 Republicans vying to take over the governor's mansion from outgoing Republican Gov. Sam Brownback. On the Democratic side, former Wichita Mayor, Carl Brewer and six other Democrats will fight for the seat.
In Wisconsin, Democratic U.S. Sen. Tammy Baldwin will run for re-election this year along with Republican Scott Walker, who's seeking his third term as Wisconsin's Governor. Arkansas Gov. Asa Hutchinson, a Republican, will also run again in 2018.
But the electoral dynamics in those states are very different than in Kentucky.
The work requirement offers Bevin, a conservative Republican, an opportunity to deliver on a campaign vow to switch to the federal government’s insurance marketplace and impose conservative policy changes to the Medicaid program. That’s a radical departure from his predecessor, former Democratic Gov. Steve Beshear, who embraced the Affordable Care Act’s expanded Medicaid eligibility and created a state-run insurance marketplace.
Plus, there are no major statewide races set for this year, so the Medicaid change will not be a major ballot-box issue for Bevin and most Kentucky Republicans. In addition, low-income voters who’ll be affected by Medicaid work requirements historically turn out at lower rates than the general electorate. And that could help insulate Republicans from any possible election-year blowback if the Medicaid policy proves unsuccessful in Kentucky, Cross said.
Furthermore, in November 2016, Trump lost two of the three counties with the most number of Medicaid enrollees but still carried the state by a wide margin, winning 62.5 percent of the vote.
But if it pays off politically in Kentucky, will it do elsewhere? That’s far from certain. And it may depend on rival Democrats making a linkage between Medicaid and overall concerns about health care and insurance.
Health coverage is a potent election-year issue for Democrats. Polling last week by Hart Research Associates showed health care tops the economy, taxes, immigration and terrorism as a voter priority in the 2018 congressional elections.
New Gallup poll estimates released Tuesday show 3.2 million Americans lost health coverage in 2017 as the nation’s uninsured rate climbed 1.3 percent, the largest one-year increase since Gallup began tracking the data in 2008.
For example, in Kansas, which may be one of the next states to impose Medicaid work requirements, the political dynamics are different.
"I think, politically, Democrats will make some hay out of it and moderate Republicans will see it as punitive and going along with an administration that has not been helpful on Medicaid,” said Burdett Loomis, a political science professor at the University of Kansas. Loomis added who added that imposing the work requirement could backfire in a state where many support expanding Medicaid eligibility under the Affordable Care Act.
A Kaiser Family Foundation study estimates that 60 percent of Medicaid enrollees are already employed, and 35 percent of non-working Medicaid enrollees say illness or disability is the main reason for their unemployment. In addition, 28 percent reported care-taking obligations, while 18 percent couldn’t work because they were in school. Women made up sixty-two percent of Medicaid recipients without jobs in 2015, Kaiser reported.
Add up those findings, Loomis said, and the work requirement policy is mostly symbolic.
"It ends up playing to this notion that all these people are getting something for nothing, when, in fact, if you look at Medicaid that's really not the case," he said.
Tony Pugh: 202-383-6013, @TonyPughDC