Work Requirements and Perceived Deservingness of Medicaid

• Author: Jennifer D. Wu
• Date: 01 January 2021
• Published date: 01 January 2021
• DOI: 10.1177/1532673X20961317
• Subject Matter: Articles

https://doi.org/10.1177/1532673X20961317

American Politics Research

2021, Vol. 49(1) 30 –45

© The Author(s) 2020

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DOI: 10.1177/1532673X20961317

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Article

What makes someone deserving of federally-funded health

insurance? Logic from the welfare literature would suggest

that deservingness is partly a function of how much a person

has done to earn their aid (Cook & Barrett, 1992). This is

often referred to as reciprocity. However, much of the work

that has been done looking at the deservingness of health

insurance focuses on what an individual has done to incur

their health-related illness such that they need to access the

health care system in the first place, often referred to as

responsibility. One issue encountered in the health deserv-

ingness literature is that studies often conflate deservingness

of health insurance with deservingness of health care. While

the concept of responsibility applies cleanly to the provision

of health care, this is less true when we consider provision of

health insurance. This paper attempts to answer the question

of what makes someone deserving of health insurance by

examining the role the dimensions of responsibility and reci-

procity play in shaping perceptions of deservingness.

Understanding attitudes toward provision of health insur-

ance using logic from the welfare literature is of particular

importance given the current discourse around the American

healthcare system. Healthcare in the United States has con-

tinually differentiated itself from the rest of the developed

world with regard to in its means of provision (Bundorf &

Fuchs, 2008; Ellis et al., 2014; Reinhardt, 2019, p. 82).

While other developed nations have some form of universal

coverage, the United States provides government-funded

health insurance through two main programs, Medicare and

Medicaid. Though the two programs have similar objectives

in providing insurance to the otherwise uninsured, Medicare

provides coverage for the elderly, whereas Medicaid pro-

vides coverage for low-income individuals. It is not surpris-

ing, then, that when respondents are polled for their support

for a Medicare-For-All type expansion of government provi-

sion, polling results score relatively high (e.g., see Kirzinger

et al., 2018). This is concerning because while Medicare-for-

All, a point on which many primary candidates have cam-

paigned on in the 2020 election cycle, finds broad support,

its support is nonetheless generated on the basis of attitudes

toward a different population group than Medicaid.

According to a report from the Kaiser Family Foundation,

65% of survey-takers were able to correctly identify Medicaid

as being the program for low-income people, while 72%

were able to correctly identify Medicare as the program for

people over 65 (Kaiser Family Foundation [KFF], 2015).

That is to say, people do have some understanding of who

Medicare is intended for (and to a lesser extent, Medicaid as

well). When campaigns use slogans such as “Medicare-For-

All,” they may inadvertently be priming positive attitudes

that people associate with Medicare (KFF, 2015). It would

thus be erroneous to extrapolate attitudes based on Medicare

to predicted attitudes of nationalized healthcare. Framed

961317APRXXX10.1177/1532673X20961317American Politics ResearchWu

research-article2020

1Yale University, New Haven, CT, USA

Corresponding Author:

Jennifer D. Wu, Yale University, 115 Prospect St., New Haven, CT 06520,

USA.

Email: jennifer.wu@yale.edu

Work Requirements and Perceived

Deservingness of Medicaid

Jennifer D. Wu1

Abstract

Does an individual’s effort to acquire employer-sponsored health insurance through employment affect whether they are

deserving of health insurance? Much of the current literature that examines the deservingness of federally-funded health

insurance focuses on an individual’s responsibility in becoming ill. However, logic from the welfare literature would suggest

the willingness to work for one’s welfare, or reciprocity, is an important determinant of deservingness. The relevance

of employment-seeking in Medicaid deservingness comes at a crucial time given recent attempts by state governments

to implement work requirements as a part of Medicaid eligibility. Using a series of survey experiments, I compare the

importance of responsibility versus reciprocity and find that responsibility, what one does to become ill, is the primary driver

of judgments of deservingness. What one does to earn their Medicaid by working plays a negligible role in driving attitudes.

These findings have implications for how we understand the determinants of support for Medicaid policy.

Keywords

public opinion, policy attitudes, deservinginess, Medicaid, work requirements

Wu 31

differently, how would these polls look if instead of a

“Medicare-for-all” plan, respondents were presented with a

“Medicaid-for-all” plan? Medicaid and Medicare cover

relatively different populations and attitudes may not be

consistent across recipient populations.

If we were to extend health insurance to the currently unin-

sured, it is unlikely that the population pool would resemble

those currently on Medicare. While there is variation in

demographic characteristics, the uninsured population gener-

ally tend to be male, low-income, non-Hispanic White, living

in the South, and have a high school education or lower

(Berchick, 2017; Blumberg et al., 2018). Would individuals

from these demographics be perceived as deserving of some

form of federal assistance? More importantly, who do people

think of as being recipients of Medicaid, a social welfare

program, and are they perceived as deserving of federal

assistance? These questions are an important precursor to

understanding support for expansion of health insurance pro-

vision. Research that examines support for welfare programs

establishes a positive correlation between perceptions of a

recipient group’s deservingness of program benefits and sup-

port for that program (e.g., Appelbaum, 2001; Gilens, 1999;

Gollust & Lynch, 2011; Petersen, 2012; Skitka & Tetlock,

1993; van Oorschot, 2000). Relevant to this study, we can

draw two salient questions from extant work. The first is

whether the recipient group is deserving or not. If people do

not believe program beneficiaries deserve to receive pro-

grammatic aid, then we would expect them to support the pro-

gram less (Petersen et al., 2012). The second is whether

individuals would support the program, even if they believe

the recipient population to be deserving. Support for a social

program can remain low for reasons related to distrust of fed-

eral agencies, an unwillingness to pay into a program from

which others may use heavily that they themselves are not are

using, disagreement about how the program is implemented,

etc. (Bundorf & Fuchs, 2008; DeScioli et al., 2018;

Hetherington & Globetti, 2002; Rudolph & Evans, 2005).

This paper focuses on the first question of identifying rel-

evant determinants of recipient deservingness and leaves the

second question to the realm of work done on risk-pooling

and insurance. Drawing from extant work on program

deservingness, I identify two dimensions that are particularly

relevant to Medicaid provision and work requirements: reci-

procity, what a policy beneficiary does to earn or payback

federal assistance, and responsibility, how much control a

policy beneficiary had in incurring the need for assistance in

the first place. Specifically, I focus on the role of work

requirements in affecting an individual’s perceived deserv-

ingness of federally funded health insurance. “Community

engagement” requirements, as they are officially described,

have been introduced in the discussion of restructuring

Medicaid eligibility. As of 2019, Arizona, Indiana, Michigan,

Ohio, Utah, and Wisconsin have successfully waived regu-

lations against having work requirements as part of Medicaid

eligibility. At least seven more states have filed similar

waiver requests (Kaiser Family Foundation, 2019). The State

Medicaid Director Letter issued to describe the potential

introduction of community engagement requirements stipu-

lates that individuals subjected to the work/community

engagement requirements are those who are “eligible for

Medicaid on a basis other than disability” (CMS, 2018). The

range of applicable activities that would satisfy the require-

ments include career planning, job training, volunteering,

and so on. However, these descriptions rely on the premise

that a majority of current Medicaid recipients are not already

involved in such endeavors, which is empirically not the

case. Data from the Kaiser Family Foundation show that in

2016, approximately 60% of Medicaid recipients are work-

ing either full time or part-time. Among the remaining 40%

of recipients who are not working, only 7% to 8% are not

working for reasons related to disability, illness, caregiving,

or school attendance. In other words, it is to this 7% to 8% of

individuals that work requirements would be targeting. The

consequence of augmenting eligibility guidelines to target a

relatively small portion of recipients is that current individu-

als who are on Medicaid for any of the other reasons may

find themselves ineligible, should they not meet the new

work requirements (Garfield et al., 2019).

In order to test the relevance of work requirements (i.e.,

reciprocity) as a means of evaluating an individual’s deserv-

ingness of federally funded health insurance, I employ a

series of survey experiments which ask respondents to evalu-

ate a hypothetical individual who is uninsured and needs

health insurance. In addition to varying the individual’s level

of reciprocity, I also randomize his level of responsibility. The

results from the survey experiment suggest that an individu-

al’s level of responsibility is far more salient in informing

people’s judgements of his deservingness, more so than reci-

procity. In a second set of survey experiments, I confirm that

respondents’ attitudes are driven more by learning what type

of person is a recipient, rather than by attitudes toward the

program itself. In the following, I describe extant work that

has been done on the issues of deservingness and policy pro-

gram support, both in the general policy arena as well as

health policy. I then present the research question and describe

the experimental designs implemented to test the relevant

hypotheses. I conclude with a discussion of the implications

of these results on Medicaid programming and design.

Background

Deservingness and Program Support

Support for social programs can be broken down to two

dimensions: program effectiveness and attitudes toward the

recipient population. Whether a program is effective in

addressing the policy issue it was meant to address and

whether it is efficiently implemented naturally has an effect

on whether there is support for it. It could be the case that

while people support the intention of a policy, they do not