Oklahoma’s plan for Medicaid work requirements is a dangerous experiment that will put the health of thousands of Oklahomans at risk (Guest post: Philip Rocco)

Philip Rocco is an Assistant Professor of Political Science at Marquette University and co-author of Obamacare Wars: Federalism, State Politics, and the Affordable Care Act (University Press of Kansas, 2016). This post is excerpted from a public comment authored by he and his colleagues.

The healthcare of thousands of Oklahomans is on the line this fall. That’s because Gov. Mary Fallin and the Oklahoma legislature have developed a plan to require low income parents or caregivers to work at least 20 hours a week in order to maintain their SoonerCare coverage. If the federal government approves the plan, it will place young parents, caregivers, and their children at risk of losing SoonerCare.

Work requirements will have negative effects on the health of thousands of low-income Oklahoma families. Especially for mothers, young parents, and children who benefit from SoonerCare––the vast majority of whom already work––work requirements will create a bureaucratic maze. Those who fail to get exemptions from the state or who fail to comply with complex details of the new requirement could soon lose coverage. This is to be expected. While work requirements tend not to enhance individuals’ earnings or job prospects, they will create red tape that makes it harder for individuals to access needed services.

[pullquote]“ The Governor and Legislature have placed the Oklahoma Health Care Authority (OHCA) in the impossible position of having to defend the argument that work requirements will improve health.”[/pullquote]

This is happening because the Governor and Legislature have placed the Oklahoma Health Care Authority (OHCA) in the impossible position of having to defend the argument that work requirements will improve health. Unsurprisingly, OHCA’s application is based on a misleading and inaccurate representation of published research on the link between employment and health.  In its letter to State Medicaid Directors, the Centers for Medicare and Medicaid Services (CMS) asks states to demonstrate a link between work and positive health outcomes. Oklahoma’s application claims that, “the correlation between employment and health for the general population is well established” in the research literature. Yet this reflects a basic lack of understanding of the research cited in the application. Consider the following examples:

• OHCA cites a 2005 meta-analytic study to support its argument that work requirements will enhance the well-being of SoonerCare members. Yet this misrepresents the authors’ findings. Not only do the authors fail to establish a causal relationship between unemployment and mental health, they argue that their correlative evidence shows that: “…there are several aspects of unemployment experience (e.g., financial concerns, work-role centrality) that are the actual factors responsible for reduced well-being during unemployment; meaning a causal suggestion of a relationship between unemployment and mental health is molar in nature, or at a very broad level.”
• OHCA cites a 1995 study in support of its proposed amendment. Yet this study does not show the causality implied by OHCA. While the authors argue that full-time employment is associated with slower declines in physical and psychological function, they also find that, “physical functioning increases the odds of getting or keeping a full-time job for both sexes.”
• OHCA also cites a study examining a hypothesis formulated by social psychologist Marie Jahoda that employment is the only source of five “latent functions” in society that sustain mental health. Yet the study draws on a web-based survey undertaken in Germany, which has a universal multi-payer system and compulsory health insurance. This is a very different system than the United States, and comparing these findings to the context of the United States is inappropriate.

Simply, the evidence does not support the argument that tying work requirements to health care access will improve health outcomes.

[pullquote]“Oklahoma’s application defines success not as improved health for SoonerCare beneficiaries, but lower utilization of health care services. In other words, success means fewer people receiving healthcare. .”[/pullquote]

Even if OHCA’s unsupported assertion that employment improves health status and functionality were true, none of the hypotheses developed by OHCA in its evaluation design relate to the effect of work requirements on these outcomes. In fact, Oklahoma’s application defines success not as improved health for SoonerCare beneficiaries, but lower utilization of health care services. In other words, success means fewer people receiving healthcare. One surefire way to achieve this would be to limit individuals’ eligibility for SoonerCare.

The bottom line is this: the Governor and Legislature are asking state officials to conduct a dangerous experiment on low-income Oklahomans. That will put the health of thousands of people at risk.