The Catch-22 of Work Requirements for Public Assistance and Medicaid

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The Catch-22 of Work Requirements for Public Assistance and Medicaid

Catherine W. Britell, M.D.

Meaningful work that pays for housing, food, clothing, transportation and health care is something almost everyone wants for themselves and every society wants for as many as possible of its members. For the past 30 years, my job has been to identify and address the health and rehabilitation issues of individuals of differing abilities, some of whom would be considered “disabled” under Social Security standards; but most of whom would be considered to be “able-bodied” by our politicians. Most are living in poverty and some are homeless. As part of interdisciplinary teams that enable these individuals to achieve independent living and self-supporting employment, I have had an opportunity that few other physicians or others in the community have — to understand what it takes for a person to become successfully employed. So — what does it take?

1. Good health. You can’t work or go to school when you’r sick — physically, mentally or both. People who are chronically unemployed often have had poor diet and living conditions and no access to health care. They have chronic health conditions that must be addressed before they can work. Diabetes, heart disease, infectious diseases such as tuberculosis and Hepatitis C are common in this population. Mental health issues such as depression, anxiety, or bipolar disorder are frequently experienced by chronically unemployed individuals (either as a cause or result of unemployment). You need to have a stable ongoing relationship with a primary practitioner, and have access to appropriate specialty care, including mental health care as needed.
2. Optimal vision and hearing. These individuals likely have not had vision or hearing exams, many may require glasses, hearing aids, or accommodation for sensory disabilities.
3. Dental health. Most individuals who are chronically unemployed have not had access to dental care, often have decaying teeth, bad breath, and dental pain. These people are not acceptable in most educational and work settings until their dental problems are remediated.
4. Freedom from addiction. The chronically unemployed are at high risk for addiction. The reasons for this include chronic pain from a high rate of physical injury, chronic anxiety due to lack of physical safety and security, and lack of social support and appropriate sources of joy and satisfaction. Addiction treatment takes time, money, and also treatment/mitigation of other factors (particularly chronic pain, homelessness and mental health issues) that cause/promote it. An addicted person cannot hold down a job or take advantage of education/training.
5. Accommodation to disability. When you see a person in a wheelchair with a spinal cord injury or cerebral palsy, a person using American Sign Language, or a person who has Down Syndrome, it’s pretty obvious that they’ll need one or more accommodations for successful job training and employment. They will need to work with a therapist or assistive technology specialist to get the appropriate equipment, and staff may need to help the employer make the workplace accessible. Many more chronically unemployed individuals, however, have less obvious disabilities. For example, people who have specific learning disability, ADHD, or mild autism spectrum disorder may have just been considered “unmotivated” in school, may have had no special evaluation or assistance and dropped out. Many of these people have low self-esteem and have been told they are “stupid”. Often a neuropsychological evaluation is needed to determine the individual’s learning ability and determine what accommodations will be required for work or job training and extensive counseling and support will be required to get the individual successfully trained and employed.
6. Stable, functional independent living. In order to be successful at work or school, a person must have a good night’s sleep, a convenient place to do personal hygiene, clean clothes and a place to store them, secure medication storage, and convenient and nutritious meals. Many homeless programs, shelters, and “tiny house” solutions offer people a way to survive; however many if not most are set up so that it is impossible to take care of one’s daily personal needs efficiently enough to get to a job in a reasonable time. People need stable housing with efficient access to kitchen, bath, and laundry in order to spend a full day at school or on the job. For people with physical disabilities an accessible living situation is necessary. Often a professional independent living assessment will be required and possibly attendant care for assistance with activities of daily living, housework, and meal preparation will be required.
7. Safe and efficient transportation. Chronically unemployed individuals don’t have money for bus transportation to school or work, let alone to own a vehicle. Furthermore, if a person has a mobility impairment, accessible public transit is necessary; and perhaps a special accessible van service.

So, that’s what it takes to enable a person to work. We who are employed sometimes take these things for granted — unless we spend some time learning about the serious challenges faced by the chronically unemployed.

In February 2018, The Trump Administration determined that states may institute work requirements for “able-bodied” individuals to receive Medicaid. Some states already have work requirements for other forms of public assistance. To do this puts the chronically unemployed in a no-win situation. They can’t get healthy until they are employed, and they can’t be employed until they’re healthy. Furthermore, many require “health” services from rehabilitation therapists, vocational counselors, assistive technology specialists, independent living specialists and psychologists/learning specialists in order to be successfully employed.

To expect people to be employed or in training before they can access health and rehabilitative services is cruel and cynical, and will only serve to keep the poor poorer and sicker, and thus costing MORE money in emergency health care and support. We can choose to do what it takes to get people employed….or we can put them into a cruel, genocidal Catch-22.