Summary
A central question in the current debate over work requirements
in Medicaid is whether such policies promote health and are therefore within
the goals of the Medicaid program. Work requirements in welfare programs in the
past have had different goals of strengthening self-esteem and providing a
ladder to economic progress, versus improving health. This brief examines
literature on the relationship between work and health and analyzes the
implications of this research in the context of Medicaid work requirements. We
review literature cited in policy documents, as well as additional studies
identified through a search of academic papers and policy evaluation reports,
focusing primarily on systematic reviews and meta-analyses. Key findings
include the following:
·
Being in poor health is associated with increased risk of job
loss, while access to affordable health insurance has a positive effect on
people’s ability to obtain and maintain employment.
·
There is limited evidence on the effect of employment on
health, with some studies showing a positive effect of work on health yet
others showing no relationship or isolated effects. There
is strong evidence of an association between unemployment and
poorer health outcomes, but authors caution against using these findings to
infer that the opposite relationship (work causing improved health) exists.
While unemployment is almost universally a negative experience and thus linked
to poor outcomes, especially poor mental health outcomes, employment may be
positive or negative, depending on the nature of the job (e.g., stability,
stress, hours, pay, etc.). Further, most studies note major limitations in our
ability to draw broad conclusions on health and work, including:
o
Job availability and quality are important modifiers in how work
affects health; transition from unemployment to poor quality or unstable
employment options can be detrimental to health.
o
Selection bias in the research (e.g., healthy people being more
likely to work) and other methodological limitations restrict the ability to
determine a causal work-health relationship.
·
Studies note several caveats to and implications of the research
on work and health that are particularly relevant to work requirements in
Medicaid. For example:
o
The work-health relationship may differ for the Medicaid
population compared to the broader populations studied in the literature, as
Medicaid enrollees report worse health than the general population and face
significant challenges related to social determinants of health.
o
Limited job availability or poor job quality may moderate or
reverse any positive effects of work.
o
Work or volunteering to fulfill a requirement may produce
different health effects than work or volunteer activities studied in existing
literature.
o
Loss of Medicaid coverage under work requirements could negatively
impact health care access and outcomes, as well as exacerbate health
disparities.
Introduction
On January 11, 2018, CMS issued a State Medicaid Director Letter providing
new guidance for Section 1115 waiver proposals that would impose work
requirements (referred to as community engagement) in Medicaid as a condition
of eligibility. On January 12, 2018, CMS approved the first work
requirement waiver in Kentucky, and three
additional work requirement waiver approvals followed in Indiana (February
1, 2018), Arkansas (March 5, 2018), and New Hampshire (May 7, 2018). The
new guidance and work requirement approvals reverse previous positions of both
Democratic and Republican Administrations, which had not approved work
requirement waiver requests on the basis that such provisions would not further
the Medicaid program’s purposes of promoting health coverage and access.
However, in both the new guidance and work requirement waiver approvals, CMS
explains its policy reversal by maintaining that employment leads to improved
health outcomes, and policies that condition Medicaid eligibility on meeting a
work requirement will further this objective. Though the structure of work
requirements is similar to those used in other programs, the administration’s
stated goal of improving health through Medicaid work requirements is
different from the goals of welfare reform work requirements in the past, which
were to strengthen self-esteem and provide a ladder to economic progress.
On June 29, 2018, the DC federal district court vacated HHS’s approval of
the Kentucky Section 1115 waiver program. The court held that consideration of
whether the waiver would promote beneficiary health in general is not a
substitute for considering whether the waiver promotes Medicaid’s primary
purpose of providing affordable health coverage and remanded to HHS to consider
how the waiver would help furnish medical assistance consistent with Medicaid
program objectives. However, the court also noted that plaintiffs and
their amici assert that proclaimed health benefits of employment are
unsupported by substantial evidence. Thus, there is likely to be ongoing debate
and policy discussion over whether work requirements will further the aims of
Medicaid.
To address whether work will further the aims of Medicaid, we
examine the literature on the relationship between work and health and analyze
the implications of this research in the context of Medicaid work requirements.
Due to the large number of studies in this field spanning decades, this
literature review focuses primarily (although not exclusively) on findings from
other literature or systematic reviews rather than individual studies on these
topics. We drew on studies cited in policy documents on work requirements in
Medicaid, results of keyword searches of PubMed and other academic
health/social policy search engines, and snowballing through searches of
reference lists in previously pulled papers. In total, we reviewed more than 50
sources, the vast majority of which were published academic studies or program
evaluations and most of which are reviews of multiple studies themselves. A
more detailed description of the methods underlying this analysis is provided
in the Methods box at the end of this brief.
What effect do health and health coverage have on work?
Not surprisingly, research has demonstrated that being in poor
health is associated with an increased risk of job loss or unemployment.1,2,3,4,5 A
meta-analysis of longitudinal studies on the relationship between health
measures and exit from paid employment found that poor health, particularly
self-perceived health, is associated with increased risk of exit from paid
employment.6 Another
study that simultaneously examined and contrasted the relative effects of
unemployment on mental health and mental health on employment status in a
single general population sample found mental health to be both a consequence
of and a risk factor for unemployment. However, the evidence for men in
particular suggested that mental health was a stronger predictor of subsequent
unemployment than unemployment was a predictor of subsequent mental health.7 Additional
research suggests that, in some cases, individual characteristics such as
income, race, sex, or education level may mediate the relationship between poor
health and unemployment.8,910 Research
also demonstrates that an unmet need for mental health or substance use
disorder treatment results in greater difficulty with obtaining and maintaining
employment.11,12,13,14,15
Additional research suggests that, in addition, access to
affordable health insurance and care, which may help people maintain or manage
their health, promotes individuals’ ability to obtain and maintain employment. For
example, in an analysis of Medicaid expansion in Ohio, most expansion enrollees
who were unemployed but looking for work reported that Medicaid enrollment made
it easier to seek employment, and over half of employed expansion enrollees
reported that Medicaid enrollment made it easier to continue working.16 Similarly,
a study on Medicaid expansion in Michigan found that 69% of enrollees who were
working said they performed better at work once they got coverage, and 55% of
enrollees who were out of work said the coverage made them better able to look
for a job.17 A
study on Montana’s Medicaid expansion found a substantial increase of 6
percentage points in labor force participation among low-income, non-disabled
Montanans ages 18-64 following expansion, compared to a decline in labor force
participation among higher-income Montanans.18 National
research found increases in the share of individuals with disabilities
reporting employment and decreases in the share reporting not working due to a
disability in Medicaid expansion states following expansion implementation,
with no corresponding trends observed in non-expansion states.19 Additional
literature suggests that access to health insurance and care promotes
volunteerism, finding that the expansion of Medicaid under the ACA was
significantly associated with increased volunteerism among low-income adults.20,21
What effect does work have on health and health coverage?
Overall, the body of literature examining whether work affects
health shows mixed results, with some studies showing a positive effect of work
on health yet others showing no relationship or isolated effects. A
2006 literature review found that, while “there is limited amount of high
quality scientific evidence that directly addresses the question [of whether
work is good for your health]… there is a strong body of indirect evidence that
work is generally good for health and well-being.”22 That
assessment was based on comprehensive review of the literature, including other
systematic reviews as well as narrative and opinion pieces. A more focused 2014
systematic review about the health effects of employment, which included 33
longitudinal studies,23 found
strong evidence that employment reduces the risk of depression and improves
general mental health, yet it found insufficient evidence for an effect on
other health outcomes due to a lack of studies or inconsistent findings of the
studies.24 A
2015 review of 22 longitudinal studies found an association between employment
and re-employment with better physical health.25
In contrast, research shows a strong association between unemployment and
poor health outcomes, though researchers caution that these findings do not
necessarily mean the reverse is true (e.g. employment causes improved
health). The effect of unemployment on health has long been an area of
research focus, and a substantial body of research from the U.S. and abroad
consistently demonstrates a strong association between unemployment and poorer
health outcomes,26,27,28,29 30,31,32 with
some evidence suggesting a causal relationship in which unemployment leads to
poor health.33,34,35 The
bulk of the research in the unemployment and health field focuses on mental
health outcomes.36
Examples of negative health outcomes associated with unemployment include
increases in depression, anxiety, mixed symptoms of distress, and low
self-esteem.37,38 A
more limited body of research suggests an association of unemployment with
poorer physical health (including increases in cardiovascular risk factors such
as hypertension and serum cholesterol as well as increased susceptibility to
respiratory infections), and mortality.39,40 A
2006 literature review noted that there is continuing debate about the relative
importance of possible mechanisms involved in this relationship, and adverse
effects of unemployment may vary in nature and degree for different individuals
in different social contexts.41 Some
evidence also indicates that cumulative length of unemployment is correlated
with deteriorated health and health behavior.42 However,
despite the evidence of a relationship between unemployment and health,
researchers caution against using findings to infer that an opposite
relationship (employment causing improved health) exists.43,44 In
addition, researchers note that the literature on unemployment tends to study
more negative than positive health outcome variables,45 which
may skew our understanding of the health effects of unemployment.46
Another related area of research is studies examining the
relationship between re-employment (i.e., returning to work) and health, which
find some association between re-employment and mental health. A
2012 systematic review on this topic found support for a beneficial health
effect of returning to work, with most of the 18 studies included in this
review focusing on mental health-related outcomes.47 The
review also tried to assess to what extent the relationship was causal (i.e.,
reemployment caused health improvements) versus due to selection (e.g., people
with poor health were more likely to remain unemployed) and concluded that both
were at play. The review did not reach a definitive conclusion about mechanisms
linking re-employment to improved health (due to lack of evidence), and it
noted that it is still unclear whether health effects of reemployment are
moderated by factors such as socioeconomic status, reason for unemployment, and
the nature of employment.48 The
2006 literature review described above also analyzed research findings on
re-employment and found strong evidence that re-employment leads to improved
psychological health and measures of general well-being, with a dearth of
information on physical health and some but not all studies showing that
re-employment/health relationship is at least partly due to health selection.
However, these authors also cite evidence from numerous studies suggesting that
“the beneficial effects of re-employment depend mainly on the security of the
new job, and also on the individual’s motivation, desires, and satisfaction”49
Studies on work and health have found that the quality and
stability of work is a key factor in the work-health relationship: research
finds that low-quality, unstable, or poorly-paid jobs lead to or are associated
with adverse effects on health.50,51,52,53,54,55,56 For
example, a 2014 meta-analysis of studies published after 2004 found that job
insecurity can pose a comparable (and even modestly increased) risk of
subsequent depressive symptoms compared to unemployment.57 A
2011 longitudinal analysis found that while unemployed respondents had poorer
mental health than those who were employed, the mental health of those who were
unemployed was comparable or more often superior to those in jobs of poor
psychosocial quality (based on measures of job control, perceived job security,
and job demands and complexity) and the mental health of those in poor quality
jobs declined more over time than the mental health of those who were
unemployed. Moreover, while moving from unemployment into a high quality job
led to improvement in mental health, the transitioning from unemployment to a
poor quality job was more detrimental to mental health than remaining
unemployed.58 Additionally,
a 2003 study that examined the association of different employment categories
with physical health and depression found a consistent association between less
than optimal jobs (based on economic, non-income, and psychological aspects of
the jobs) and poorer physical and mental health among adults.59
It is possible that the work-health association reflects people in
good health being more likely to work, versus work causing good health. Some
researchers caution against the possibility that selection bias has occurred in
many of the studies on work and health. The existence of a “healthy worker
effect”—in which relatively healthy individuals are more likely to enter the
workforce whereas those with health problems are at increased risk to withdraw
from and remain outside of the workforce—has been documented in multiple
studies.60,61,62,63 64 ,65
Authors of both individual studies and literature reviews on this topic explain
that the healthy worker effect is difficult to control for even in studies that
attempt to do so, and thus this effect may cause an overestimation of the
findings in the literature on health effects of work.66,67 As
authors of a 2014 systematic review of studies on health effects of employment
point out, there are no randomized controlled trials on this topic available in
the literature because performing such trials would be unethical,68 yet
randomized controlled trials are the gold standard for determining a causal
relationship.
Most study authors specifically note additional caveats to drawing
broad conclusions about work and health. The
2006 review concluding a general positive effect of work on health emphasized
three major provisos to this conclusion: (1) findings are about average or
group affects, and a minority of people may experience contrary health effects
from work, (2) the beneficial health effects of work depend on the nature and
quality of work (described above), and (3) the social context must be taken
into account, particularly social gradients in health (i.e. inequalities in
population health status related to inequalities in social status) and regional
deprivation.69 These
caveats could explain the seemingly contradictory findings about employment and
unemployment: While unemployment is almost universally a negative experience
and thus linked to poor outcomes, especially poor mental health outcomes,
employment may be positive or negative, depending on the nature of the job
(e.g., stability, stress, hours, pay, etc.). As discussed below, these provisos
have implications for the applicability of research to Medicaid work
requirements.
While work can help people access employer-sponsored health
coverage, many jobs—especially low-wage jobs—do not come with an affordable
offer of employer coverage. In 2017, just over half
(53%) of firms offered health coverage to their employees,70 and
workers in low-wage firms are less likely than those in higher wage firms to be
eligible for coverage through their employer.71 In
2017, less than a third of workers who worked at or below their state’s minimum
wage had an offer of health coverage through their employer.72 Though
most employees take up employer-sponsored coverage when offered, workers in
low-wage firms are less likely to be covered by their employer even if coverage
is offered, likely reflecting the fact that workers in such firms pay a larger
share of the premium than workers in higher-wage firms.73 The
fact that work does not always lead to health coverage is further demonstrated
by the large majority of uninsured people who are in a family with either a
full-time (74%) or part-time (11%) worker.74
What is the effect of volunteerism on health?
In the January 2018 guidance, CMS includes volunteering as a
“community engagement” activity that may improve health outcomes,75 and
the Medicaid work requirement waivers approved to date all permit volunteer
activities to count towards the required weekly/monthly hours of work activity.
However, there is limited existing evidence that volunteer
activities benefit health outcomes. One literature review on
the health effects of volunteering “did not find any consistent, significant
health benefits arising through volunteering” based on experimental studies
available at the time of the literature review.76The
authors’ analysis of cohort studies revealed limited benefits of volunteering
on depression, life satisfaction, and well-being (with no significant benefits
on physical health). In addition, the cohort studies focused primarily on volunteers
ages 50 and over, with some of the studies suggesting that the association
between volunteerism and improved health outcomes may be limited to older
volunteers and that that the health benefits of volunteering may diminish as
hours of volunteering increase.77 Another
study (published in 2018) examined the health benefits of “other-oriented
volunteering” (other-regarding, altruistic, and humanitarian-concerned
volunteering) compared to “self-oriented volunteering” (volunteering focused on
seeking benefits and enhancing the volunteers themselves in return). While the
authors found beneficial effects of both forms of volunteer activity on health
and well-being, other-oriented volunteering had significantly stronger effects
on the health outcomes of mental and physical health, life satisfaction, and
social well-being than did self-oriented volunteering.78 As
discussed below, this finding may indicate that health benefits of volunteering
are likely to be weaker when individuals are compelled to engage in
volunteering.
What does this research mean for Medicaid work requirements?
The body of literature summarized above includes several notable
caveats and conclusions to consider in applying findings to a work requirement
in Medicaid. Limitations and implications that are particularly relevant
include:
Effects found for the general population may not apply to
Medicaid, as the link between work and health is not universal across
populations or social contexts. In general, the studies
examined above analyze the relationship between work and health among broad
populations of all income levels. However, several authors suggest that
population differences may modify the relationship between work and health.
A 2003 study found that nationally, older adults, women, blacks, and
individuals with low education levels were more likely to be employed in jobs
viewed as “barely adequate” or “inadequate” (the types of jobs that the study
found to be independently associated with poorer physical health and higher
rates of depression) compared to other populations.79 Authors
of a 2006 literature review qualify their broad findings on the work/health
relationship with the proviso that the social context must be taken into
account (particularly social inequities in health and regional deprivation),
and also cite evidence that the strong association between socioeconomic status
and physical and mental health and mortality likely outweighs (and is
confounded with) all other work characteristics that influence health.80 Authors
of a 2005 review on unemployment and health found a strong association between
deprived areas, poor health, poverty and unemployment (although the exact
relationship is not clear), and highlight the need for more research on the
geographical dimension on unemployment and health.81 These
findings imply that the work/health relationship may differ significantly for
the low-income Medicaid population, who report worse health status compared to
the total US population and often face more significant challenges related to
housing, food security, and other social determinants of health.82,83,84 In
addition, some volunteerism research suggests that the association between
volunteerism and improved health outcomes may be limited to older volunteers,
yet approved and pending Section 1115 Medicaid work requirement waiver requests
all include exemptions for individuals above a certain age (which varies by
state but ranges from 50 to 65 years).85
Work or volunteering undertaken to fulfill a requirement may
produce different health effects than work and volunteer activities studied in
existing literature. For example, research on health effects of
work requirements in Temporary Assistance for Needy Families (TANF) suggests
that they did not benefit and sometimes negatively affected health among
enrollees and their dependents.86 Another
study found that welfare reform was associated with increases in self-reported
poor health and self-reported disability among white single mothers without a
high school diploma or GED.87 These
adverse effects could reflect different relationships between work and health
for low-income populations, as described above, or different effects of work
undertaken voluntarily versus as a requirement. Authors of a 2006 literature
review on work and health found that forcing claimants off benefits and into
work without adequate supports would more likely harm than improve their health
and well-being.88 Similarly,
most studies on volunteerism and health define volunteerism as an act of
free-will (essentially, a voluntary act), a definition that may not be
applicable to volunteer activity undertaken for the purpose of meeting
work/community engagement requirements in order to maintain eligibility for
Medicaid. Volunteer activities undertaken to retain Medicaid appear more
closely aligned with the self-oriented form of volunteerism (volunteering
focused on seeking benefits and enhancing the volunteers themselves in return),
which research shows has weaker health effects than the other-oriented form
(other-regarding, altruistic, and humanitarian-concerned volunteering).
Limited job availability, low demand for labor, or poor job
quality may moderate any positive health effects of employment. Authors
of a 2014 systematic review of prospective studies on health effects of
employment commented that most studies in this field do not adjust for quality
of employment and include all kinds of jobs in their analysis (e.g. part- and
full-time employment, self-employment, and both blue- and white-collared jobs)
despite the possibility that different forms of employment have different
health effects.89 Under
Medicaid work requirement programs, the population subject to Medicaid work
requirements may have access to only low-wage, unstable, or low-quality jobs to
meet the weekly/monthly hours requirement, as these are the types of positions
adults with Medicaid who currently work hold.90 In
discussing the policy implications of their findings, multiple researchers have
concluded that such policies could be detrimental to health, with authors of
one study asserting that, “Policies that promote job growth without giving
attention to the overall adequacy of the jobs may undermine health and
well-being.”91
Long-term effects of work on health are unclear. Much of
the evidence on the work/health relationship is about short-term effects after
about one year, which, as authors of one literature review point out, is a
short period when assessing health impacts.92 There
is less evidence on longer-term effects over a lifetime perspective.93 In
addition, research on work requirements in other public programs shows little
evidence of long-term impacts on employment or income. Studies on welfare recipients
subject to work requirements generally have found that any initial increase in
employment after an imposition of a work requirement faded over time.94,95,96 After
five years, one study showed those who were not required to work were just as
likely or more likely to be working compared to those who were subject to a
work requirement, suggesting that these work requirements had little impact on
increasing employment over the long-term.97 Other
research has found that employment among people who left welfare was unsteady
and did not lift them out of poverty.98 Thus,
even short-term effects are likely to disappear as short-term boosts in
employment fade over time.
Loss of health insurance coverage due to not meeting reporting or
work requirements under waivers could affect access to health care and
health. Low-wage workers typically work in small firms and industries
that often have limited employer-based coverage options, and very few have an
offer of coverage through their employer. Work requirements in Medicaid could
lead to large Medicaid coverage losses, especially among people who would
remain eligible for the program but lose coverage due to new administrative
burdens or red tape versus those who would lose eligibility due to not working.99 Several
studies on individuals leaving TANF following welfare reform show reductions in
insurance coverage across this “welfare leaver” population, with significant
decreases in Medicaid coverage that were not fully offset by the smaller
increases in private coverage.100,101,102,103,104 A
study evaluating welfare-to-work interventions found that some programs led to
a reduction in health insurance coverage for both children and parents.105
Given the evidence of Medicaid’s positive impact on access to care and health
outcomes,106 as
well as data demonstrating that uninsured individuals go without needed care
due to cost at much higher rates than those with Medicaid coverage,107 widespread
coverage losses as a result of Medicaid work requirements are likely to result
in adverse effects on health outcomes. In TANF evaluations, for example,
studies found that children of TANF enrollees who lose benefits for failure to
comply with a work requirement experience adverse health effects such as
behavioral health problems108 or
hospitalization.109
Policies that have disproportionate effects on certain Medicaid
enrollees could widen health disparities. Data demonstrate
the persistence of clear disparities in health insurance coverage, access to
care, and health outcomes for certain vulnerable populations in the US,
including people with disabilities (compared to their non-disabled
counterparts)110 and
people of color (compared to whites).111 Research
shows that people with disabilities and people of color are face
disproportionate challenges in meeting and are disproportionately sanctioned
under existing work requirement programs.112,113 If
racial minority groups, people with disabilities, or other vulnerable
populations face similarly disproportionate challenges in meeting work
requirements when they are attached to the Medicaid program, these policies
could result in wider disparities in health insurance coverage and health
outcomes.
Looking Ahead
Taken as a whole, the large body of research on the link between
work and health indicates that proposed policies requiring work as a condition
of Medicaid eligibility may not necessarily benefit health among Medicaid
enrollees and their dependents, and some literature also suggests that such
policies could negatively affect health. While it is difficult to determine a
causal relationship between employment and health status (largely due to
challenges controlling for health selection bias and the inability to conduct
randomized controlled trials on this topic), there is strong evidence of an
association between employment and good health. However, research suggests that
factors like job availability and quality, as well as the social context of
workers, mediate the effect of work or work requirements on health. Given the
characteristics of the Medicaid population, research indicates that policies
could lead to emotional strain, loss of health coverage, or widening of health
disparities for vulnerable populations. As debate considers the question of
whether policies to promote health—versus health coverage—are the aim of the
Medicaid program, the question of whether work requirements will promote health
also will remain key to the ongoing debate over the legality of work
requirements in Medicaid.
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Methods
This brief is based on a review of existing research on the
relationship between work and health. To collect relevant studies, we began
by drawing on studies cited in policy documents on work requirements in
Medicaid, including the January 2018 guidance from CMS, comments and
reactions to the guidance, and documents related to the Stewart
v. Azar litigation and decision. We then conducted keyword
searches of PubMed and other academic health/social policy search engines to
compile relevant studies and program evaluations. Due to the large
number of studies in this field spanning decades, we focused primarily
(although not exclusively) on findings from other literature or systematic
reviews rather than individual studies on these topics. We then used a
snowballing technique of pulling additional studies from reference lists in
previously pulled papers. In areas with limited evidence or in which reviews
indicated conflicting or unclear results, we looked at original source
studies to understand findings and assess the strength of the evidence.
In total, we reviewed more than 50 sources, the vast majority
of which were published academic studies or program evaluations and most of
which are reviews of multiple studies themselves. In weighing evidence, we
prioritized recent research and research based in the United States over
older research and research based on experiences in other countries, though
we did include older and international studies if they were highly cited,
directly relevant, or included in systematic reviews that also included
US-based studies. We excluded commentaries (as compared to original work or
comprehensive literature reviews) and studies that were not directly focused
on the link between health and work (e.g., we excluded studies of workplace
wellness programs).
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