Experiences with Work and Participation in Public Programs by Low-Income Medicaid Enrollees Using Qualitative Interviews.

BACKGROUND: Centers for Medicare & Medicaid Services (CMS) began encouraging governors to implement work requirements for Medicaid enrollees using section 1115 waivers in 2018. Significant controversy surrounds such attempts, but we know little about the perceptions and experiences of enrollees. OBJECTIVE: To characterize experiences of work and its relationship to participation in Medicaid and other public programs among potential targets of Medicaid work requirements. DESIGN: In-depth, semi-structured, one-time qualitative interviews. PARTICIPANTS: 35 very low-income, non-disabled Medicaid expansion enrollees participating in a county-sponsored Medicaid managed care plan as a part of a larger study. APPROACH: We used a biographical narrative interpretive method during interviews including questions about the use of employment and income support and other public programs including from state and federal disability programs. Our team iteratively coded verbatim transcripts allowing for emergent themes. KEY RESULTS: Interview data revealed high motivation for, and broad participation in, formal and informal paid work. Eight themes emerged: (1) critical poverty (for example, "I'm not content, but what choices do I have?"); (2) behavioral and physical health barriers to work; (3) social barriers: unstable housing, low education, criminal justice involvement; (4) work, pride, and shame; (5) inflexible, unstable work (for example, "Can I have a job that will accommodate my doctor appointments?…Will my therapy have to suffer? You know? So it's a double edged sword."); (6) Medicaid supports the ability to work; (7) lack of transparency and misalignment of program eligibility (for example, "It's not like I don't want to work because I would like to work. It's just that I don't want to be homeless again, right?"); and (8) barriers, confusion, and contradictions about federal disability. CONCLUSIONS: We conclude that bipartisan solutions prioritizing the availability of well-paying jobs and planful transitions off of public programs would best serve very low-income, work-capable Medicaid enrollees.