Understanding the Intersection of Medicaid, Work, and COVID-19
Prior to the pandemic, there was a lot of interest in the work status of Medicaid enrollees as the Trump administration issued guidance for demonstration waivers, inviting states to impose work requirements in state Medicaid programs as a condition of eligibility. A number of states had such waivers approved, but litigation challenging these requirements stopped the implementation of work requirements in all states but Utah. On April 3, Utah announced suspending its work requirement due to the coronavirus pandemic.
The coronavirus pandemic carries both health and economic implications. Many individuals enrolled in Medicaid are employed in industries particularly at risk for income or job loss (such as food and other service industries) or at risk of contracting COVID-19 (such as health care or grocery industries) because they remain exposed to individuals in public/service settings. Many individuals who currently have job-based or other private coverage may become newly eligible for Medicaid if they lose their jobs; however, Medicaid coverage options will be more limited in states that have not adopted the ACA Medicaid expansion (though many not eligible for Medicaid in these states will be eligible for ACA premium subsidies, particularly in the near term after accounting for new federal unemployment benefits). Due to maintenance of eligibility requirements in the Families First Coronavirus Response Act (FFCRA), those who had Medicaid coverage as of March 18, 2020 should be able to maintain their current coverage through the end of the public health emergency. The pandemic is likely to underscore the role that Medicaid plays as a coverage safety-net. This will be the first economic downturn that the ACA – including expanded Medicaid eligibility and premium subsidies for those with somewhat higher incomes – is in place to cushion the effect of coverage losses as people lose their jobs.
This brief analyzes data about the work status and characteristics of Medicaid enrollees prior to the pandemic. The brief also includes perspectives from Medicaid enrollees who participated in focus groups in three cities (Cleveland, Detroit, and Milwaukee) in January 2020 involving their experiences with work or barriers to work. Data and enrollee perspectives from before the pandemic provide key context for examining the implications of the coronavirus crisis for this population and the potential effects of the pandemic on their jobs, health, and financial security.
Data examined includes non-dual, non-SSI, nonelderly adults with Medicaid (referred to throughout the brief as “Medicaid adults”). National and state data tables are included as Appendix Tables. The enrollee perspectives are based on six focus groups representing a total of 52 Medicaid enrollees. Two groups were held in each of three sites (Cleveland, Detroit and Milwaukee) with Medicaid workers and non-workers participating in separate groups. Focus groups were conducted by the KFF, working with PerryUndem Research/Communication, during January 2020. Additional interviews were conducted with Medicaid managed care plans, work force services, health care providers, and other individuals with insights into the Medicaid population and the issues around work to help inform the study.
Work Status of Medicaid Adults Prior to COVID-19 and Implications of COVID-19
Prior to the COVID-19 crisis, most Medicaid adults were working or faced potential barriers to work (Figure 1). Survey data from 2018 reveal that, overall, more than six in ten (62%) non-dual, non-SSI, nonelderly adults with Medicaid (referred to hereafter as “Medicaid adults”) were working either full or part-time. Illness or disability were primary reasons for not working among remaining Medicaid adults. Caregiving responsibilities or school attendance were other leading reasons reported for not working. The remaining eight percent of Medicaid adults reported that they are retired, unable to find work, or were not working for another reason. The pandemic is likely to result in job loss for those who were working and could exacerbate barriers to work such as increased caregiving responsibilities.
Those in better health and with more education are more likely to be working (Appendix Table 1). Health status is the strongest predictor of work, with people in “excellent” or “very good” self-reported health thirty percentage points more likely to be working than those reporting “fair” or “poor” health. Education level is also a strong predictor of work status. Rates of work also vary by geographic region, age, and race/ethnicity. Medicaid adults living in the South are less likely to be working compared to other regions. Because Medicaid eligibility levels for adults (parents and childless adults) are lower in the South, fewer adults who work can qualify for Medicaid compared to other regions. Those middle aged (26-45) and male are more likely to work than other ages and females (Appendix Table 1).
Implications of COVID-19 for Medicaid Workers
Many Medicaid enrollees are employed in occupations where they may face health risks from coronavirus if they are able to maintain their jobs or are deemed “essential” workers. For example, many adults enrolled in Medicaid work as cashiers, in the health care sector, or have jobs as drivers or janitors where they are in contact with other people putting them at greater risk for exposure to COVID-19 (Figure 2). (Not shown in Figure 2 below, over 300,000 “waiters and waitresses” were covered by Medicaid in 2018.) In addition, as states begin to ease social distancing requirements at different rates, people who are able to return to work could be at greater risk for exposure to COVID-19. As noted later, many Medicaid enrollees may have underlying health conditions that put them at greater risk of serious illness and death if they were to contract COVID-19. Even prior to the pandemic, Medicaid enrollees noted they sometimes had to take jobs that they knew could have negative health implications (e.g., jobs that require manual labor).
Many Medicaid adults who work were employed by small firms and in industries that have likely been affected by COVID-related job loss. Prior to the pandemic, more than four in ten Medicaid workers were employed in firms with fewer than 50 employees. These firms are less likely to offer health benefits and are not subject to ACA penalties for not offering affordable health coverage (Figure 3). Many Medicaid workers reported limited fringe benefits: only 32% of Medicaid workers reported access to paid sick leave (data not shown).1 Only 10% of Medicaid workers reported being members of a union (data not shown),2 which generally use collective bargaining to negotiate higher wages or benefits for their members.
Almost four in ten working Medicaid adults were employed in ten industries in 2018, with more than one in ten enrollees working in restaurants or food services (Figure 4). The next largest group of Medicaid workers were employed in the construction industry. (Not shown in Figure 4 below, nearly 450,000 adult workers with Medicaid coverage were employed by department or discount stores or nursing facilities in 2018.) State comments on current 2020 unemployment data filings indicate that most claims are for people previously employed in service industries, particularly accommodation and food services, with an increasing rate for people in retail, wholesale trade, and construction industries.3
One in three Medicaid adults who were working prior to the pandemic were working part-time due to challenges that could be made worse by COVID-19. Among Medicaid adults who work, about half (49%) worked full-time (at least 35 hours per week) for the entire year (at least 50 weeks) (Appendix Table 2 and Figure 5).4 Full-time work of 35 hours or more per week may be from more than one job (other data show that nearly one in ten Medicaid workers have more than one job).5 One in three Medicaid adults were working part-time. Some cited reasons for working part-time such as school or training (16%) or other family or personal obligations (18%); but a large share pointed to work limits such as shorter work weeks (less than 35 hours per week) (13%), slack work/business conditions (14%), or inability to find full-time work (9%) (Figure 5). Personal issues related to childcare or other caregiving responsibilities are likely to become greater challenges due to the economic conditions and widespread closures of schools and day care facilities from the pandemic. For example, for those that maintain jobs, they might see reduced hours, more fluctuation in incomes / schedules, or they might struggle to maintain work with lack of child care options.
Experiences of enrollees show that even prior to the pandemic, there was a high degree of instability in availability of work for Medicaid enrollees. Some enrollees described limited ability to work more due to hours availability in food service or catering jobs or because some work was seasonal or already highly variable (e.g., landscaping or construction). One focus group participant noted her family owned a landscaping business and did snow removal during the winter. However, snowfall is unpredictable, so they tried to build up a reserve from summer work to survive the winter. In addition, without benefits like paid sick leave, some focus group participants said they had difficulty maintaining jobs. The FFCRA provides emergency short-term paid sick leave and longer-term paid family leave for workers affected by coronavirus, however, not all employees are eligible for these benefits leaving gaps in benefits for many who might need them.
“Family issues like my father he doesn’t work he’s older, he has health issues so like he gets sick hey, I gotta go, you know, and if the job doesn’t give me FMLA… I just can’t work here no more.” Female, Worker Ohio
“That’s why I work for Uber, I can do my own hours…that’s why I got a job like that so I wouldn’t have to deal with having to take time off or have to have a certain amount of sick time.” Male Worker, Wisconsin
“With Target hours now, they get cut through January and February so I’m like getting like nothing right now…they’ve only given me sometimes four hours a week. That was shockingly even low too for this year, because last year I was like at 40 hours. So, it was a big difference.” Female Worker, Wisconsin
Health and Financial Security Among Medicaid Enrollees and Implications of COVID-19
Medicaid adults that are working are generally healthier than non-workers but many still have significant health issues that could put them at greater risk of serious illness or death from COVID-19. Medicaid adults workers who participated in focus groups in January 2020 were experiencing a number of chronic conditions that would place them at higher risk for serious illness if infected with coronavirus including heart disease, chronic obstructive pulmonary disease (COPD), uncontrolled asthma, diabetes, or a BMI greater than 40. Other conditions mentioned by working focus group participants included Lupus, high blood pressure, high cholesterol, asthma, mental health conditions (e.g., depression, anxiety, ADHD and substance use disorders), migraines, sleep apnea, fibromyalgia, and neuropathy. Medicaid coverage helped enrollees manage chronic conditions and supported their abillity to work prior to the pandemic. Many enrollees cited need for access to medication or prescription drugs to manage chronic illnesses that would be too expensive without Medicaid. However, in light of coronavirus, those with underlying health conditions face higher health risks if they continue to work but also face financial consequences from failure to work or job loss.
“Yeah so like when the lupus flair ups there are days when like I can’t even get out of bed because like my entire body is in pain, and like that’s like, you know, like a huge inconvenience, but like it has definitely gotten better over the past couple of years.” Male Worker, Ohio
Well I’m a recovering addict and this year in August I’ll have 4 years clean… so I had a rough, I want to say, like from late 20s, so that got me out of like swept me off my feet for a while…but I mean thank God like my old employers like they still like hired me back like after and everything like that.” Female Worker, Ohio
“I take my medicine for my high blood pressure, so it’s, it’s leveled out, it’s taken care of, and I don’t feel like I’m going to like die from a heart attack or anything like that so, I feel great with my health.” Female Worker, Wisconsin
“I got a lot of issues…I have sleep apnea and asthma, um, high cholesterol, fibromyalgia… some random things, but I’m taking a lot of medications and stuff.” Female Worker, Wisconsin
“I mean I’ve dealt with mental health issues my entire life and still take medication for it. So, I mean it’s a constant, everyday thing, but… comes and goes, depends on the day really. I mean some days are good, some days are bad.” Male Worker, Wisconsin
“If I wouldn’t have any of the medication that I’m on. Who knows where I would be…since I was in my early 20’s diagnosed with the depression, anxiety and all that good stuff. And, without the medication it definitely is, um, more severe for me…the medication definitely keeps me more level and if I didn’t have insurance, I think each of those medications are like $100 something and that’s like way more than I can afford per month.” Male Worker, Wisconsin
“If I didn’t have it [Medicaid] I’d be dead. My insulin and diabetic supplies run about $2,000 a month by themselves. That doesn’t even include the high blood pressure and the high cholesterol stuff that I’m on. So, if I didn’t have it, I wouldn’t be here.” Male Worker, Wisconsin
As more Medicaid workers lose jobs due to COVID-19, they are likely to experience even greater levels of financial and food insecurity. Prior to the COVID-19 crisis, non-workers and workers enrolled in Medicaid were facing financial insecurity. Survey data from 2018 revealed even when working, adults with Medicaid face high rates of financial and food insecurity, as they were still living in or near poverty. About half reported that they were “very” or “moderately” worried they would not have enough money to pay normal monthly bills, and four in ten said they were “very” or “moderately” worried about having enough money for housing (Figure 6), rates similar to non-working adults with Medicaid. More than a quarter (26%) of working and 35% of non-working Medicaid adults said they “sometimes” or “often” worry that food will run out, and high shares also reported that they have experienced problems such as food running out before funds were available to buy more, having to cut meal size or skip meals, not eating due to lack of money, losing weight, or not eating for an entire day (Figure 7). While food assistance programs are available to low-income people, these programs do not reach everyone who faces food insecurity.6
Recent polling shows that one in four Americans (26%) say they or someone in their household have skipped meals or relied on charity or government food programs since February, including 16% who say this was due to the impact of coronavirus on their finances. The share who say they have skipped meals or relied on charity or government food programs due to coronavirus is higher among those in households that have lost a job or income due to coronavirus (30%) and among Black adults (30%) and Latinos (26%).
Both Medicaid enrollees who were working and not working provided details about financial struggles living near or below poverty that are likely to be worse with the economic fall-out from the pandemic. Enrollees across the focus groups reported they were living pay-check to pay-check, including those who were working. Many were dealing with debt from credit cards or student loans. Costs of rent, child care, utilities, and groceries were ongoing issues but unexpected costs like car repairs added to financial stress. Many noted it was hard to “get ahead.” Even if they got a small pay increase, rent was going up faster or an unexpected expense made it difficult to move out of poverty.
“It’s just hard, you know, like I have a cellphone, but my phone doesn’t work because I can’t pay the bill for it. I’m in debt for like $160 on it at this point…it’s hard to apply for a job if they can’t reach you.” Male Non-Worker, Ohio
“My car broke down four times this month, I just got it out the shop, and yeah I don’t know when this thing is just going to completely go down. First it was the battery, then I replace the battery, then the starter went out, then once I got a new starter, the transmission line burst while I was on my way to school. And then now I just got it out the shop, but it’s just one thing after another, so like I just know that at some point, it’s gonna go and it’s not gonna come back. And then, I mean of course I got a lease termination because I’m behind on my rent.” Female Non-Worker, Ohio
“We had our lights cut off before because we were trying to juggle with the car and the rent.” Female Non-Worker, Ohio
“A lot of times like I can find a job, but $15, even at $15 an hour, once you take away Medicaid, and once you take away food stamps, then you have to pay out your pocket for your own insurance, and then you have all of your other expenses on top of that. Like it still feels like you’re just living from paycheck to paycheck, robbing Peter to pay Paul.” Female Non-Worker, Ohio
“For me like, uh, I’m doing fine, just you worry that emergency happen or you can’t work or, that’s what you worry about. As long as I’m working, I feel things is okay, but uh.” Male Worker, Wisconsin
Even prior to the pandemic when economic conditions were generally favorable, enrollees reported difficulty moving up from lower paying to higher paying and more stable jobs. Available jobs often paid low hourly wages that were not sufficient to cover living expenses. Enrollees reported feeling like they were “treading water” as they were often underemployed and stuck in low wage jobs, living pay check to pay check.
“I could get a thousand McDonald’s jobs, but that’s not going to pay my bills at the end of the month. Even if I worked a hundred hours a week it’s still not going to be enough. So, I think there are jobs but the quality of the job that you’re looking for is not always there.” Female Worker, Michigan
“…there all the 1099 work out there, where people are full time workers…but they’re a subcontractor just to make it cheaper for the employer, so that means you can’t afford benefits…” Male Worker, Michigan
“My field is pretty gig-based economy kind of stuff so it’s living contract to contract and sometimes it’s long dry spells.” Male Non-Worker, Wisconsin
“If anything, you know you’re just treading water…you’re not looking for jobs as much anymore. Right because you’re stuck in that kind of job, you don’t have the time to look for another job.” Female Non-Worker, Wisconsin
The coronavirus pandemic is expected to exacerbate financial insecurity for Medicaid enrollees. School and day care closures as well as limited access to food and other supports as a result of the pandemic are likely to increase financial insecurity. For those who are able to maintain jobs, issues related to access to child care and other supports could affect ability to work.
Unquestionably, the outlook will be challenging from both public health and economic perspectives. For Medicaid enrollees, the pandemic will likely result in many enrollees losing their jobs as the industries where Medicaid enrollees work are likely to be hardest hit by the pandemic. Medicaid enrollees who were not working are likely to face the same barriers that affected them before the pandemic (e.g., underlying health conditions and caretaking responsibilities) as well as additional barriers to finding work due to the rapidly deteriorating economic situation. For enrollees who continue to work, Medicaid will be an important support as Medicaid workers are employed in jobs that may face high risk of contracting coronavirus. Medicaid enrollees working and not working reported high levels of financial insecurity prior to the pandemic which is likely to continue or worsen under new and deteriorating economic conditions. Recent federal legislation passed provides “maintenance of eligibility” protections to ensure continued coverage for Medicaid enrollees. In addition, Medicaid – along with ACA premium subsidies – will act as a coverage safety-net for many who lose jobs and income and newly qualify. Coverage options will be more widely available in expansion states where eligibility for Medicaid is available for nearly all adults with incomes up to 138% FPL compared to non-expansion states where more people experiencing job loss could fall into a coverage gap and become uninsured.
Robin Rudowitz, Rachel Garfield, and Elizabeth Hinton are with KFF.
Anthony Damico is an independent consultant.