As States Impose Medicaid Work Requirements, an Analysis Finds Little Evidence That Employment Improves Health

As states seek to implement waivers that will allow them to require some Medicaid beneficiaries to work in order to remain eligible for their benefits, a key and so far unanswered question is whether work itself promotes better health.

A new report from the Kaiser Family Foundation (KFF) sought to answer that question by examining available research from more than 50 sources on the relationship between work and health. It found that while unemployment is linked with poor outcomes, employment is not necessarily associated with health improvements.

Unsurprisingly, the report found a link between poor physical or mental health and unemployment and with a risk of job loss, but the report notes nuances to that finding; poor mental health can be a consequence of—not simply a risk factor for—unemployment, and an unmet need for treatment may result in more difficulty obtaining and maintaining employment.

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At the same time, access to affordable healthcare was linked with better ability to seek or maintain employment. The report notes that in Medicaid expansion states, there were increases in the share of people with disabilities who reported employment, but no corresponding trend in nonexpansion states. Volunteerism also increased among low-income adults in connection with Medicaid expansion, and some evidence demonstrated that volunteers over age 50 experienced improvements in depression, greater life satisfaction, and an improved sense of well-being as a result of their work.

While access to care improved the ability to work, the report found less evidence that work itself improved health; although the report’s authors caution that our understanding of the health effects of unemployment may be influenced by the fact that most research on unemployment tends to study negative health outcome variables rather than positive ones, there is little conclusive evidence showing a link between work and positive health outcomes. Many studies have focused on the link between employment or re-employment and mental health (but not physical health), and these studies have demonstrated that, while employment may correspond with better outcomes, it is also possible that those whose mental health is better are more likely to be employed or re-employed.

Gains in mental health after re-employment, they note, appear to depend on factors including job security and the worker’s level of satisfaction; low-quality, unstable, and poorly paid work is associated with negative effects on health, which suggests that not all jobs can be expected to produce the same impacts on well-being. Furthermore, the fact that many low-wage jobs do not offer employer-sponsored health coverage may pose yet another barrier to improved health.

The report also highlights the fact that research on employment may be subject to the so-called “healthy worker effect,” in which individuals who are relatively healthy are more likely to enter the workforce and those who have more health problems are at greater risk to withdraw from or remain outside of the workforce. That effect appears to be supported by other research, also performed by KFF, that found that most Medicaid enrollees who are able to work already do so; that analysis found that 62% of nonelderly adults not receiving Supplemental Security Income and not eligible for both Medicare and Medicaid are already working, with 43% working full time and 19% working part time. Enrollees who are in very good or excellent health are nearly twice as likely to be working than those in fair or poor health.

While effects found in the research examined by KFF may not be broadly applicable to the Medicare population, given that health is not universal across all demographics, and while work and volunteering that are undertaken to fulfil Medicaid requirements may differ from the activities discussed in the literature, the authors say that the long-term effects of work on health are not clear, and low job availability and poor job quality could temper any positive health impacts of employment.

What is clear, however, is that loss of access to healthcare as a result of not meeting work requirements would negatively impact individuals’ health and could widen health disparities by disproportionately impacting vulnerable populations.