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Work Requirements Target the Wrong People

By KIM BELLARD

One of the key “cost savings” in last years’ Big, Beautiful Bill were work requirements imposed on most working aged beneficiaries in SNAP and/or Medicaid, despite the fact that the few times such requirements had been tried showed they were costly to implement and operate and don’t do much to increase work participation, although they are effective at getting beneficiaries to lose benefits. Republicans who pushed these requirements were infuriated at the thought that some able-bodied people – stereotypically young men – were sitting around on their couches playing video games while benefiting from the programs, despite those programs’ complex administrative burdens and meagre benefits.

A new GAO report reminds us that the people coasting off SNAP and Medicaid were not so much the beneficiaries but rather employers, especially large employers. And the names of the most likely employers won’t come as a big surprise.

The report — Federal Social Safety Net Programs: Millions of Workers, Including Many Employed by Large Employers, Continue to Rely on Medicaid and SNAP – was requested by Senator Bernie Sanders, in his role as Ranking Member of the Senate Committee on Health, Education, Labor, and Pensions, and is a follow-up to a similar 2020 report. It focused on 11 states: Arkansas, Georgia, Indiana, Maine, Massachusetts, Nebraska, North Carolina, Oklahoma, Rhode Island, Tennessee, and Washington.

The top-lines are that working aged beneficiaries in both programs were, in fact, not only likely to already be working—mostly full-time — but also at participation rates higher than working aged people not on the programs, and that companies like Amazon and Walmart were among the largest employers of these beneficiaries.

The key change in employment in these populations has been the explosion of gig workers in the app-based food delivery and ride sharing sectors. Workers at Amazon on these programs also tripled since the prior report. Walmart remains the employer with the largest number of these workers who receive Medicaid, but has slipped to second to ride sharing gig workers receiving SNAP. McDonalds and Dollar General round out the top five employers.  

Now, these are among the largest employers generally, but, gosh, doesn’t it gall you that have so many of their workers who still need SNAP and/or Medicaid?  It’s not like they’re not making money, it’s not that their CEOs and other executives aren’t raking in tens of millions of dollars, but they sure are reluctant to pay federal income taxes. The Wall Street Journal reported earlier this year that, as a result of The Big, Beautiful Bill, Amazon’s federal income taxes dropped from $9b to $1.2b in 2025, while profits soared 44.5% to $90b. Walmart looks like a sucker for paying $6b in 2025, an effective tax rate of about 23%.

An Amazon spokesperson defended its practices in a response to The Washington Post: “Amazon pay is among the best in the industry, regular full-time employees have access to health care from their first day … and 74% of our regular full-time employees are enrolled in an Amazon health insurance plan, well above the 65% private sector take-up rate for full-time workers.”

So, if all those employees have access to coverage from their first day and get among the best pay in the industry, why are any on SNAP or Medicaid?  And couldn’t you at least pay more than 1.3% on federal taxes?

Bernie, of course, was outraged:

Continue reading…

Matthew’s health care tidbits: Time to get Cynical

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

Plenty of reason to worry about the future of American health care this week. The biggest for-profit hospital chain–HCA–was accused of aggressively pushing patients into hospice care, sometimes in the same room, in order to make their hospitality mortality numbers look better. Most of the leading benefits consulting companies were exposed as taking payments from PBMs–yup, the same organizations their employer clients thought they were negotiating with on their behalf. And one of the biggest names in digital health, Babylon Health, tumbled into destitution, taking billions of dollars with it and leaving uncertain the fate of the medical groups in California it bought less than two years ago. Even the most successful capitalists in health care — United HealthGroup and its fellow insurers — saw their stock fall because apparently outpatient surgery volume is ticking up. 

On the policy front the malaise is spreading too. The end of the public health emergency (remember Covid?) is being used as an excuse by the old  confederate states to kick people off Medicaid. Georgia and Arkansas appear to be bringing back work requirements, even though I thought CMS has banned them and every study has acknowledged that they are cruel and ineffective. About 20 million people got on to Medicaid during the public health emergency and KFF estimates up to 17 million may be kicked off, while over 1.7 million already have.

Finally an article by Bob Kocher and Bob Wachter in Health Affairs Scholar remins us that big academic medical centers are nowhere near ready for value-based care (VBC). Jeff Goldsmith has been vocal on THCBGang and elsewhere about how VBC is becoming a religion more than a reality. And I remind you that Humana’s MA program is still basically a Fee-For-service program in drag (even though that’s now illegal in their home state). 

I grew up in American health care expecting that eventually a combination of universal insurance mixed with value-based purchasing would lead to a series of tech-enabled companies doing the right thing by patients and making money to boot. With the managed care revolution, the ACA and the boom in digital health all firmly in the rear view mirror, the summer of 2023 is a lesson that you can never be too cynical about health care in America.

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Can Medicaid Expansion Survive?

By STEVEN FINDLAY

Amid fresh political rancor and legal machinations in the ongoing war over the Affordable Care Act (ACA), there’s a bright spot: Medicaid. At least for now.

This matters. True to predictions made by Obama and supporters when the ACA became law (2010), it has taken years and a lot of blood, sweat and tears to get to this moment.

As a reminder, the U.S. Supreme Court in 2012 ruled that states could opt out of the ACA’s Medicaid expansion—leaving each state’s decision to participate in the hands of governors and state lawmakers.

On June 7, after a 4-year pitched political battle, Virginia became the 33rd state (plus DC) to expand Medicaid under the ACA. The Virginia expansion is projected to encompass 400,000 low-income Virginians.

The state swung in favor of expansion after Democrats gained the governorship and more seats in the legislature in 2016. But, importantly, key moderate Republicans relented.

Four other non-expansion states could join Virginia over the next year or two. They are Maine, Idaho, Utah, and Nebraska.Continue reading…