The Affordable Care Act (ACA) expanded Medicaid coverage to approximately 11 million working-age adults. Critics have raised concerns about providing Medicaid to adults capable of working. Several states have proposed work requirements in Section 1115 Medicaid waivers.1,2 Although none were approved during the Obama administration, the Trump administration is willing to consider such provisions.3 Prior analyses4 estimated that half of adults eligible for ACA Medicaid expansion were employed, and 62% of nondisabled adults were working or in school. Although these national estimates of Medicaid-eligible individuals are valuable, less is known about the employment experience of actual enrollees in Medicaid expansion states and which health characteristics may keep them from working. Complementary state-level analyses are needed as individual states consider whether to propose work requirements. This study examined the demographic and health characteristics associated with the employment status of current Medicaid expansion enrollees in Michigan, which expanded Medicaid under a Section 1115 waiver to nonelderly adults with incomes at or below 133% of the federal poverty level who do not otherwise qualify for Medicaid or Medicare based on disability or other criteria.5
The study was deemed to be exempt from approval by the institutional review boards of the University of Michigan and Michigan Department of Health and Human Services. All survey participants provided verbal consent. From January 1 through October 31, 2016, we conducted a computer-assisted telephone survey in English, Arabic, and Spanish of Medicaid expansion (Healthy Michigan Plan) enrollees with at least 12 months of coverage (response rate, 54%). Sampling was stratified by income and Michigan region. Measures included demographic and health characteristics. Multivariable logistic regression analysis incorporating sampling and nonresponse weights were used to examine the association between demographic and health characteristics and the outcomes of being out of work or unable to work vs employed, adjusting for age, sex, race, health status, presence of chronic health conditions, and functional limitations. Analyses were conducted using Stata software (version 14.2; StataCorp). Two-sided P < .05 was considered to be significant.
Among 4090 surveyed Healthy Michigan Plan enrollees (weighted sample, 379 627; 48.4% male and 51.6% female; mean [SD] age, 40.36 [12.96] years), 48.8% reported that they were employed or self-employed; 27.6% were out of work, 11.3% were unable to work, 2.5% were retired, 5.2% were students, and 4.5% were homemakers. Table 1 presents demographic and health characteristics of enrollees out of work or unable to work compared with employed enrollees. In multivariable analyses (Table 2), enrollees were more likely to report being out of work if they were older, male, African American, or in fair or poor health or had mental health conditions or functional limitations. Enrollees were more likely to report being unable to work if they were older, male, or in fair or poor health or had chronic health conditions or functional limitations.
Our findings have key implications for proposed work requirement policies for Medicaid expansion enrollees. First, more than half of Michigan enrollees were already working or students and thus would not be affected by work requirements. Second, most enrollees who were unable to work reported significant barriers to employment, such as poor health, chronic conditions, older age, or functional limitations. Work requirements could disrupt coverage for such vulnerable individuals who may not meet formal criteria for disability. Third, although those who were out of work reported better health and fewer functional limitations, the proportion of Medicaid expansion enrollees overall who were not working and possibly able to work if employment were available remained small. Study limitations include self-reported outcomes, single state data, and lack of information about whether enrollees were looking for work or had other barriers, such as caregiving responsibilities (thus, the proportion of those not working or looking for work may be lower than our estimates). States should consider the administrative costs of implementing a work requirement program to identify and enforce employment for relatively few individuals and the risk of coverage interruptions for vulnerable individuals with chronic health conditions.
Corresponding Author: Renuka Tipirneni, MD, MSc, Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, North Campus Research Complex, Building 16, Room 419W, 2800 Plymouth Rd, Ann Arbor, MI 48109 (firstname.lastname@example.org).
Accepted for Publication: October 11, 2017.
Published Online: December 11, 2017. doi:10.1001/jamainternmed.2017.7055
Author Contributions: Dr Tipirneni had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Tipirneni.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Tipirneni, Goold.
Obtained funding: All authors.
Study supervision: All authors.
Conflict of Interest Disclosures: None reported.
Funding/Support: The study was supported by a contract from the Michigan Department of Health and Human Services (MDHHS) to the University of Michigan to conduct an evaluation of the Healthy Michigan Plan, as required by the Centers for Medicare & Medicaid Services (CMS) through a Section 1115 Medicaid waiver.
Role of the Funder/Sponsor: The funders reviewed and approved the manuscript but had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of MDHHS or CMS.
Additional Contributions: Matthias A. Kirch, MS, and Christina Mrukowicz, MPH, of the University of Michigan Institute for Healthcare Policy and Innovation, provided analytic support. Jeffrey T. Kullgren, MD, MS, MPH, Edith C. Kieffer, PhD, Ann-Marie M. Rosland, MD, MS, Tammy Chang, MD, MPH, MS, Adrianne N. Haggins, MD, MSc, Sarah J. Clark, MPH, Sunghee Lee, PhD, Erica Solway, PhD, MPH, MSW, Erin Beathard, MPH, MSW, Erin Sears, MPH, Lisa Szymecko, JD, PhD, Tolu Olorode, MSW, MUP, Cengiz Salman, MA, and Zachary Rowe, BA, of the University of Michigan Institute for Healthcare Policy and Innovation, contributed to survey design and development. All study team members are funded by the contract from MDHHS to the University of Michigan to conduct the evaluation of the Healthy Michigan Plan. Mark Fendrick, MD, of the University of Michigan Center for Value-Based Insurance Design, provided thoughtful comments on earlier drafts of this manuscript. He was not compensated for his contribution.