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Despite a relentless eight-year Republican campaign to repeal the Affordable Care Act, it remains largely intact. Through it, nearly 20 million Americans gained health insurance. Many others benefited from new protections, such as ensuring that people can’t be denied coverage because of pre-existing conditions and the elimination of limits on lifetime benefits that has protected thousands of vulnerable Americans from bankruptcy.

Unable to achieve legislative success, Republicans have found a new strategy to remake health policy: deploying administrative burdens to make it harder for millions of Americans to gain access to health care.


The Trump administration has been vigorously and effectively employing this strategy in several ways, most notably by eviscerating enrollment education and assistance for the Affordable Care Act and establishing work requirements for Medicaid.

The Affordable Care Act, like the U.S. health care system, is complex. The Obama administration used an extensive outreach campaign to explain the program, show people how they could benefit from it, and help them enroll for health insurance.

The Trump administration has done the opposite. It shortened enrollment periods from 90 days to 45. It largely eliminated advertising for the program during the enrollment period, and slashed funding for those providing enrollment help from $63 million to $10 million. New promotional materials from the government even featured videos of people explaining how the Affordable Care Act had harmed them.


The lack of outreach has increased learning costs and hurt enrollment. A Kaiser Family Foundation poll found that only one in four people who buy their own insurance knew the application deadline for 2019. Enrollment is down 4 percent in 2019, with a 15 percent drop in first-time enrollees.

The Trump administration is also using administrative burdens to limit access to Medicaid. The Centers for Medicaid and Medicare Services encouraged states to adopt new barriers, such as work requirements for beneficiaries, reflecting the president’s government-wide executive order to employ “work requirements when legally permissible.”

Proponents justify work requirements by claiming they will increase participation in the labor force. But a new analysis found that almost all Medicaid-eligible individuals already meet work requirements, limiting the potential for much additional labor force participation.

The statutory goal of Medicaid is to improve access to health care, not to enhance work. By any measure, Medicaid has succeeded with its true goal: reducing mortality, improving child health, and preventing families from falling into economic crises that can accompany devastating diagnoses like cancer.

Work requirements undermine these achievements. As courts examine if work requirements violate the central goal of Medicaid, the Trump administration claims they somehow improve health. But the opposite is closer to the truth: a good deal of evidence shows that those working in low-wage jobs are especially likely to have health problems, many of which start in childhood.

The new work requirements will limit access to Medicaid not so much because beneficiaries aren’t working but because of the new administrative hurdles they’ll face reporting on their work activities. Our new book, “Administrative Burden: Policymaking by Other Means,” finds that even minor barriers — additional paperwork, in-person interviews, providing documentation to prove everything from income and asset levels to out-of-pocket health care costs — stop people from participating in programs they would benefit from. Demands to regularly provide and submit work documentation will overwhelm many people already struggling to make ends meet in low-wage jobs characterized by unstable schedules and a greater likelihood of layoffs when the economy stalls out. Those with irregular or seasonal work will be especially disadvantaged.

The administrative burdens inherent in work requirements are easily apparent when you look at its early implementation. Arkansas was an early adopter or work requirements, the canary in the coalmine. Almost 17,000 people lost health insurance coverage in just four months. Arkansas, along with Kentucky, required online-only reporting. But 30 percent of Medicaid adults report that they never use computers, 28 percent say they do not use the Internet, and 41 percent do not use email. It is unrealistic to expect that such a population will possess the technological literacy to navigate online documentation.

While Republicans might quietly hope that these burdens will save money, the belief is likely erroneous. Tracking people’s payments and work efforts requires a whole new — and expensive — bureaucracy. States generally don’t want to hire new employees, so they will contract out the work to for-profit contractors, whose profit incentives encourage them to skimp on the quality of the services they provide.

We can all relate to the irritations of unnecessary administrative burdens, but when they stand between you and access to something as essential as health insurance, they are not simply frustrating. They can prove deadly.

Pamela Herd is professor of public affairs and sociology at the McCourt School of Public Policy at Georgetown University. Donald P. Moynihan is the inaugural McCourt chair at the McCourt School.

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