Watching the news leading up to — and following ­— the midterm elections, it has become increasingly apparent that as a country we have abandoned a general sense of kindness in favor of political tribalism. The biblical concepts of generosity, humanity, and neighborly love are convenient selling points that are all too often inconvenient in practice or policy. In an environment in which fact-based policy has taken a back seat to anecdotal rhetoric, we find ourselves searching for the moral high ground amid towering false truths.

Our English forefathers, 450 years ago, tried to distinguish between what they called the deserving poor (individuals who wanted to work but could not) and the idle poor (individuals who were able to work but were simply “lazy”). In 2018, we are still following their lead, further muddying the waters of healthcare policy.

For example, in 2018, the Centers for Medicare and Medicaid Services (CMS) began supporting state efforts to add a work requirement — or in some cases, a volunteer requirement — being linked to Medicaid coverage. This is possible under the 1962 Social Security Act; section 1115 allows for an “experimental, pilot, or demonstration project” aimed at “promoting the objectives of the Medicaid program.”1 It hardly seems conscionable that anyone would think withholding healthcare in some way promotes it.

Essentially CMS claims to be performing an experiment based on the premise that unemployment contributes to poor health, a conclusion CMS has come to by reviewing studies that have shown an association between poor health and unemployment.1 It may be time to sit down with policy makers and explain that correlation does not imply causation.

On the surface, a plan to get able-bodied individuals back to work in order to maintain their Medicaid benefits sounds reasonable. In fact, one might go so far as to argue that getting individuals to work might help them get health insurance and thus not need Medicaid support. However, this sly argument is based on the often ignored and widely accepted fallacy that the majority of individuals who receive Medicaid assistance aren’t working. We know that the opposite is true because of numerous studies2,3 showing that the majority of Medicaid recipients are employed.

We have to wonder whether the true goal of adding a work requirement to Medicaid is to decrease expenditures while punishing the so-called idle poor. In Kentucky, Republican governor Matthew G. Bevin sought to reduce Medicaid enrollment by 16% to ensure the financial future of the program by imposing a work requirement.2 The problem with his assertion is that the numbers aren’t based on facts; there is no massive cohort of Medicaid beneficiaries sitting idle and avoiding work.

To test these claims, Anna L. Goldman, MD, MPH, of the Harvard TH Chan School of Public Health in Boston, Massachusetts, and colleagues, used the results of the 2015 Medical Expenditure Panel Survey to calculate Medicaid enrollment and expenditures and the impact of the work requirement waivers proposed by Kentucky, Indiana, Arkansas, and New Hampshire. The researchers found that if work requirements were applied nationally with all the current exemptions, only 2.1 million individuals would be at risk for disenrollment from Medicaid. This number represents only 2.8% of current Medicaid enrollees who account for a total of 0.7% of Medicaid spending.2 In the states that have expanded Medicaid coverage under the Affordable Care Act (ACA), only 3.4% of the current total Medicaid enrollment would be at risk for disenrollment — or 1.1% of total Medicaid spending. In states that did not expand Medicaid, the work requirements would affect far fewer individuals — approximately 0.8%, with a total impact of 0.04% of total Medicaid spending.2