The year is 2023, and a growing movement of Republican lawmakers are attacking sexual and reproductive health care access on all fronts. Restrictions such as the Hyde amendment have been in place for decades, but have escalated since the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization ten months ago. Millions of people across the country, and especially people of color with low incomes, are encountering increasing barriers to abortions, pregnancy-related care, gender-affirming care, and medications for chronic conditions that can affect potential pregnancies, such as methotrexate. The future of critical and often lifesaving reproductive and sexual health care is precarious in the “land of the free.”
This week, U.S. House of Representatives Speaker Kevin McCarthy dropped his legislative proposal to address the debt ceiling, which includes Medicaid work requirements. Make no mistake: Medicaid work requirements are a key component of many Republicans’ agenda to all-but-eliminate reproductive and sexual health care access and further reproductive oppression in the United States (U.S.). Republicans know that as the country’s largest public health insurance program, Medicaid plays a critical role in the struggle for equitable access to reproductive and sexual health care. It covers more than forty percent of U.S. women’s births and sixty-five percent of Black women’s’ births.* It is the leading source of family planning coverage in the U.S. All states provide Medicaid coverage for breast and cervical cancer treatment, and many programs cover aspects of gender-affirming care. Some also cover assisted reproductive technologies that are especially critical for people with chronic conditions and/or disabilities that affect fertility, as well as many lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) people. Medicaid’s critical sexual, reproductive, and broader health care coverage makes it a strategic target for Republicans who wish to restrict access.
Republicans also know that most people in Medicaid and other safety net programs work if they can.
Republicans also know that most people in Medicaid and other safety net programs work if they can. Speaker McCarthy’s proposal requires that people work a minimum number of hours each week to stay covered, yet many Medicaid beneficiaries work low-wage jobs with fluctuating hours week to week. Thus, compliance is often out of their hands. Those who do not work generally cannot due to poor health or structural barriers such as a lack of access to affordable childcare, transportation, or internet access. Women and LGBTQI+ people, and especially people of color and with disabilities, also face sexism, racism, ableism, and other intersecting forms of discrimination that impede their access to employment that will satisfy work requirements.
Medicaid work requirements are just severe Medicaid cuts by another name. Decades of research and experience demonstrate that work requirements in safety net programs create burdensome and confusing red tape, paperwork, and reporting requirements that result in sweeping eligibility losses and ensure that people in poverty stay in poverty. Take Arkansas, the only state to test work requirements in a Medicaid context. In the first month that Arkansas’ work requirement penalties went into effect, they ended Medicaid coverage for 4,300 people. In 2018, over 18,000 people with low incomes lost their Medicaid coverage because they could not meet the new requirements. That is 18,000 people who lost access to affordable and comprehensive and affordable health coverage, including sexual and reproductive health care coverage, and suffered worse health and economic outcomes as a result. For example, people reported rationing their medications, delaying their care, and accumulating increased medical debt.
It appears that McCarthy modeled his Medicaid work reporting requirements proposal off longstanding and similarly punitive requirements in the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) program, which have long undermined reproductive justice by impeding program access. Congress imposed work requirements on SNAP (formerly known as the Food Stamps program) beginning in 1971, and TANF in 1996. Throughout the decades, work requirements have operated as tools of gender, reproductive, and class oppression for women, LGBTQI+ people, and their families, and especially Black, Latine, and other people of color. For example, we know that SNAP and TANF work requirements are hard to meet, especially for those who do not have equal access to the societal supports necessary to participate consistently (e.g., Medicaid beneficiaries), as well as interpersonal violence (IPV) survivors, who often face abuse that interferes with work participation. TANF work requirement programs are often far from peoples’ homes or conducted outside of regular daycare hours, making it all-but-impossible for many, including parents, to satisfy them. Because safety net programs largely serve the same populations of people with low incomes, we already know that women, LGBTQI+ people, and parents enrolled in Medicaid would face many of these same barriers to Medicaid work requirements. Work requirements also neglect or discount caregiving responsibilities, which women disproportionately bear. McCarthy’s proposal seeks to systematically decimate coverage for and endanger the health and lives of these populations.
McCarthy’s proposed work requirement exemptions are also misleading. We know from experience that exemptions from safety net program work requirements are extremely difficult to obtain. In addition to the issues that I addressed above, people who are pregnant, have disabilities, or have caregiving responsibilities may struggle to prove that they qualify for exemptions. Beneficiaries also often experience significant power differentials with program caseworkers, who have a great deal of discretion in whether to grant work requirement exemptions, and often arbitrarily refuse them. For example, in a 2022 study, caseworkers screened few women for IPV, a TANF work requirement exemption, and did not consider the exemption for them. When applicants revealed their IPV experiences, caseworkers still often refused waivers that they should have granted. These same power dynamics would severely restrict Medicaid beneficiaries’ ability to obtain McCarthy’s proposed pregnancy-related, disability-related, caregiving, and other exemptions. Many people will fall through the cracks and lose their Medicaid coverage. Given the current political landscape in the U.S., some states may even attempt to leverage pregnancy-related exemption data to further their abortion-related surveillance and criminalization efforts, in violation of federal law.
Medicaid work requirement proposals have long been a cornerstone in Republican campaigns to end access to affordable health coverage, a basic human right, for those they deem unworthy. In this moment, they will only serve to further gut access to reproductive and sexual health care for people with low incomes, and especially parents, Black, Latine, and other people of color, and people with disabilities. Protecting Medicaid is a sexual and reproductive health and justice imperative. We cannot afford to lose.
* Of note, women are not the only people who need sexual and reproductive health care. More inclusive data collection and analysis are needed to help us better understand how Medicaid helps people across gender identities, and particularly transgender, intersex, and nonbinary people, access reproductive and sexual health care.
