Yale Journal of Health Policy, Law, and Ethics

“Everybody Knows I’m Not Lazy”: Medicaid Work Requirements and the Expressive Content of Law

Kristen Underhill

ABSTRACT.  In a historic first for the Medicaid program, the Department of Health and Human Services under President Trump allowed states to establish work requirements for program participants who are considered “able-bodied adults.” These mandates were halted by litigation, and President Biden’s administration is now in the process of withdrawing the waivers. But early experiences with Medicaid work requirements suggested that they can produce widespread losses of benefits. In addition to affecting access, work requirements and other conditions on public benefits can serve an expressive purpose: they provide a source of information about a state’s values, goals, and beliefs about beneficiaries. Beneficiaries are one audience for this expressive message, but we know little about what they hear when their state makes benefits more difficult to access.

This Article presents an original empirical study of more than 9,000 Medicaid beneficiaries in the Commonwealth of Kentucky, the first state approved for a work requirement program. Using a mix of survey data and qualitative interviews, this Article demonstrates that Medicaid beneficiaries understand work requirements as providing information about the state’s values and priorities. But depending on their priors, beneficiaries interpreted these messages very differently. Many found work requirements unfair and expressive of disregard toward themselves and other beneficiaries; others believed, however, that the state had validated their identities as taxpayers.

This Article presents these findings and considers implications for expressive theories of law, shifting the paradigm to emphasize that the expressive impacts of law will depend on who is listening.

AUTHOR. Kristen Underhill, Associate Professor of Law, Columbia Law School; Associate Professor of Population & Family Health, Mailman School of Public Health, Columbia University. This Article arises from my work as a co-principal investigator of the independent evaluation of the Medicaid § 1115 waiver in the Commonwealth of Kentucky. The research in this Article was funded by the Commonwealth through Medicaid funds for evaluation (which are a combination of state and federal Centers for Medicare & Medicaid Services funding).

RECOMMENDED CITATION. Kristen Underhill, “Everybody Knows I’m Not Lazy”: Medicaid Work Requirements and the Expressive Content of Law, 20 YALE J. HEALTH POL’Y L. & ETHICS  (2021).