OKPOLICY.ORG
In a recent debate sponsored by the Oklahoma Council of Public Affairs, Forbes blogger and Manhattan Institute Fellow Avik Roy argued against expanding Medicaid in Oklahoma to provide coverage for the 140,000 working-age Oklahomans with incomes below the federal poverty level trapped in the state’s “coverage crater,” because they make too much to qualify for traditional Medicaid but are too poor to receive federal subsidies on the health insurance marketplace. Those people, he said, should simply get a job.
He said a full-time job pays enough for a household of one to earn over 100 percent of the federal poverty level, making them eligible for subsidies on the health insurance marketplace. He also argued that many workers would have access to insurance through their jobs (despite the fact that employer-sponsored insurance is declining). The Oklahoman endorsed Roy’s comments, agreeing that most uninsured Oklahomans can qualify for health insurance via employment.
As simple as Roy’s solution for the uninsured may sound, it isn’t based in reality. As we will show, a job isn’t automatically a ticket to subsidized insurance, full-time employment isn’t possible for everyone, and for a variety of reasons, many unemployed persons will not be hired for the jobs available.
A job may not be enough to qualify for subsidized insurance
Oklahoma’s unemployment rate is low compared to the national average, but Oklahoma remains a low-wage state. One in every three jobs in Oklahoma is in an occupation where the median annual pay is below poverty level. It’s not enough to simply get a job: you have to get the right job, too.
Mr. Roy’s assessment also assumes that the uninsured don’t have children or other dependents. A single mother with two children would need to earn $19,970 per year to qualify for subsidies on the health insurance exchanges. That’s $4,000 more than minimum wage (of course, if we raised the minimum wage, the gap would be smaller).
Full-time work isn’t always an option
Working full time isn’t an option for some. Caring for small children, or elderly relatives – or dependents with disabilities – can take more time than a forty hours/week job allows.
Access to full-time work also has racial disparities. In a 2009 survey, Black workers were two and a half times more likely than white workers to report working part-time jobs because it was the only employment they could find. White workers were more likely to report they were working part-time because they were also attending school.
Speaking of which: if a student is over age 26, and therefore ineligible for coverage by a parent’s insurance, refusing to expand coverage can make insurance inaccessible for college students. Continuing education is a pathway to better employment opportunities, and it’s a path more could take, if they had access to affordable health care while returning to school.
Furthermore, even if a job is available, there’s still the matter of being able to physically get to the job. Oklahoma has very little accessible public transportation: a survey of the country’s top 100 metro areas found that less than one-third of jobs in Tulsa and Oklahoma City were accessible via public transit. Don’t have a car? You might not be able to get to your job at all. Car broke down? Not being able to get to work can be grounds for dismissal. And if you lose your job for whatever reason and your income drops below poverty level, you lose your subsidies – and are uninsured again.
Proponents of expanding coverage aren’t holding the poor to lower standards than the middle and upper classes. Rather, they recognize that the poor can face serious difficulty just accessing everyday mechanisms of survival and prosperity that more well-off households take for granted. Policymakers need to remember that.
The jobs aren’t always there – and applicants can’t always get them
For many would-be applicants, the jobs simply aren’t there. While Oklahoma boasts a low unemployment rate, the overall rate masks significant disparities. Although only one in twenty Oklahomans is unemployed, of the 92,000 Oklahomans who were unemployed in 2011, nearly one-quarter had been unemployed for a year or more, and research shows that the long-term unemployed face discrimination in the hiring process. There’s also the issue of nonworking Oklahomans who, discouraged by the lack of job opportunities available, have stopped looking, and thus go uncounted in unemployment statistics. Furthermore, eastern Oklahoma has a persistently higher unemployment rate than the rest of the state; and the unemployment rate for Black Oklahomans is consistently twice that of white Oklahomans, and has been since the 1940s.
Similarly, just because a job’s available doesn’t mean an applicant can get it. Skills mismatches disqualify many applicants. The state’s efforts to attract highly skilled, high-paying jobs don’t necessarily translate to jobs for those who don’t have the requisite training or experience; as this report shows, by 2020, nearly 60 percent of jobs in Oklahoma will require a professional certificate or college degree – which only one in three Oklahomans currently have. Oklahoma’s college graduation rate is among the lowest in the US.
Finally, most companies won’t consider hiring applicants with criminal records. One in twelve adult Oklahomans has a felony conviction. That’s a lot of people who are automatically disqualified for many jobs, especially jobs that are full time and above poverty level, or that offer health insurance. Mr. Roy spoke disparagingly of the uninsured with criminal records, describing it as a “personal choice.” However, people with mental illnesses and substance abuse disorders are overrepresented in state prisons, and states that have expanded Medicaid have found that it can reduce crime by keeping the formerly incarcerated healthy and less likely to relapse into addiction or destructive behaviors. The opportunity to extend coverage to those recently released from prison is a feature, not a bug, and would make Oklahoma healthier and safer for all.
The bottom line
If you’re poor and uninsured, you can just get a job that brings in enough to obtain insurance — unless your job pays too little to get you over the poverty line, you are taking care of young children or disabled relatives, you are going to school, you are discriminated against, you don’t have access to transportation, you are struggling with mental illness or addiction, you live in a rural or high-poverty area of the state where jobs aren’t available, or you have a felony record.
Until we accept federal funds to expand coverage, the 140,000 Oklahomans who fall into one or more of these categories are out of luck.
