Why Republicans think that insurance should be tied to employment — and that it’s not essential to have at all.
“The idea of requiring Medicaid enrollees to work barely registered eight years ago, the last time Republicans debated deep health care cuts as part of their effort to repeal Obamacare. They failed to pass a law that time.
This time they were successful. That’s in part because Republicans have put more stock in an idea that has long been a part of the American conversation about health insurance: that it is a benefit one earns by working. Work requirements have overwhelming support among Republicans, and polls have found that about half of Democrats back the idea, too.
Democrats have warned that some people who do work will lose Medicaid because they can’t file the right paperwork. Republicans concede that this is possible, but that it isn’t nearly as harmful as liberals think.
This is the second key idea that helped move the coverage cuts forward: the belief that health insurance coverage isn’t actually an essential benefit. Research connecting health insurance to better health outcomes is surprisingly mixed, with multiple, large-scale studies either not finding a relationship or showing one only among especially sick patients. If this is true, it’s because the United States’ large uninsured population has forced the creation of a vast, ad hoc safety net that fills the gaps in a patchwork system.
[..] the concept of linking health insurance to employment remained a potent one for Americans. In my own reporting, I’ve often spoken to people with private insurance who were resentful that others who did not work suddenly had free health coverage. They would point out that Medicaid coverage seemed better than what they got at work. And those people weren’t necessarily wrong: Medicaid only rarely charges deductibles or co-payments, whereas the average employer plan now has a nearly $2,000 deductible before it kicks in.
[..] Multiple, large-scale studies have looked at the relationship between insurance coverage and health outcomes — and sometimes found that it’s not as obvious as you might expect.
The first randomized study on the topic, conducted in the 1970s, found that making health care more expensive did not lead to bad health outcomes for patients. Another high-profile study from M.I.T. and Harvard economists, published in 2013, looked at what happened after Oregon held a lottery for Medicaid coverage (the state was doing a limited expansion and did not have the money to cover everyone who wanted to sign up). It found some improvements in mental and financial health but, again, did not show improved physical outcomes.
“For most people, insurance coverage has little or no impact on objective measures of health,” concluded Joel Zinberg and Liam Sigaud, the authors of the Paragon study.
Many health economists would dispute that claim. Newer research that uses bigger data sets has started to find that insurance coverage, and Medicaid in particular, does lower death rates. The connection is strongest when researchers look at older, sicker populations.
There is also the financial and mental strain of lacking coverage, which can affect a person’s well-being but wouldn’t turn up in a study that strictly measured physical health outcomes. In my 15 years covering America’s health system, I’ve talked to more uninsured patients than I can count who are too scared to go to the doctor because they fear a large bill on the other end.
But the ideas that the Paragon paper articulated, which have also come up in writing from experts at the Cato Institute and the Heritage Foundation, have increasingly found a receptive audience in Washington. [..]
In 1965, the federal government began funding a few “neighborhood health clinics” in poor areas of the country. The number grew to over 100 by the 1970s. The government has continued to plow more funds into the program. There are now about 15,000 federally funded clinics that help serve the poor and uninsured. These centers are required to offer a sliding payment scale based on the patient’s ability to pay.
The people who lose health insurance “can walk into those facilities and receive totally free primary care and some secondary care, absolutely for free,” said Robert Rector, a research fellow at the Heritage Foundation.
In the 1980s, legislators were confronted with another problem: emergency rooms refusing to see patients who did not have the means to pay. This led to the Emergency Medical Treatment and Labor Act, which requires emergency rooms to provide “life-stabilizing” treatment to everyone, even the uninsured. The wait in the emergency department may be long, conservatives contend, but the patient will be seen and the emergency will be treated.
This is the Whac-a-Mole version of health care policy — an attempt to ensure that even in a system where insurance and care are tied to employment, our society protects the most vulnerable. The outcomes are decidedly mixed. Uninsured Americans may be scraping together the care they need from free clinics and emergency rooms but they may be doing so at great personal cost, arranging child care for a long wait or having their paycheck garnished when they can’t pay the medical bill.”
Full article, S Kliff, 2025.8.1