Last November, intentions to shake up safety net programs, like Medicaid, were communicated in plain English. “I know people that work three jobs and they live next to somebody who doesn’t work at all,” Mr. Donald Trump declared. “And the person who is not working at all and has no intention of working at all is making more money and doing better than the person working his or her *** off.

In April, he issued an executive order that requires Medicaid beneficiaries to seek work in order to maintain insurance benefits. Most people would agree that moving individuals from poverty to work is in fact a win/win. However, in rural areas, finding work is not that simple.

“In 2017, the Federal Government spent more than $700 billion on low-income assistance,” according to language in the executive order. “Since its inception, the [welfare] system has grown into a large bureaucracy that might be susceptible to measuring success by how many people are enrolled in a program rather than by how many have moved from poverty into financial independence.”

A closer look at Medicaid
Medicaid is a government-funded health insurance program for people with low incomes. According to, the safety net program covers more than 70 million people or one in five Americans. Medicaid covers nearly half of all births, 75 percent of poor children, and two-thirds of all nursing home residents.

Historically, Medicaid excluded low-income adults without dependent children. Medicaid roles increased with passage of the Affordable Care Act (ACA), which allowed states to opt for or against expanding Medicaid programs to low-income, childless adults. This resulted in 12 million additional enrollees who no longer had to depend on ERs as their entry into the health care system.

Missouri opted out of Medicaid expansion. According to Robert Wood Johnson Foundation (RWJF) estimates, the state has lost and is losing $17.8 billion in Medicaid funding and $6.8 billion in hospital reimbursements between the years 2013 to 2022. RWJF estimates it would have cost Missouri $1.6 billion to participate in Medicaid expansion. The Kaiser Family Foundation’s State of Health Facts reported that in 2016 Missouri ranked 49th in per capita expenditures on health care.

In states where Medicaid roles increased due to ACA, it is important to note that 60 percent of adults receiving this government-funded health insurance benefit are employed. As for those who don’t work, many are in school, have a physical or mental illness, are tasked with caring for a loved one, or have child-care challenges. Rural, able-bodied adults often face transportation barriers to get to neighboring cities where jobs are more plentiful.

Consumer advocates contend that work requirements will lead to millions of people losing assistance and don’t take into account barriers to finding employment. Rebecca Vallas, vice president of the Poverty to Prosperity Program, said, “So-called work requirements are premised on a set of myths about poverty. First, that the poor are some stagnant group of people

who ‘just don’t want to work.’ Second, that anyone who wants a well-paying job can just snap their fingers to make one appear. And third, that having a job is all it takes not to be poor.”

Rural has its own set of workforce challenges
As for rural West Central Missouri, here are just a few facts from the 2017 Missouri Economic Report that may pose challenges to meet the work requirement.

The West Central Missouri region has a higher percentage of the population with a disability compared to the state and nation. Specifically, 16 percent of the population has a disability compared with 13 percent in Missouri and 10 percent in the United States. This poses a barrier to employment or may result in working in lower skilled and lower wage jobs.
Educational attainment rates in West Central Missouri’s workforce is behind the entire state for bachelor’s or advanced degrees. Eighteen percent of the region’s workforce has a bachelor’s or advanced degree, compared with 23 percent for the state. The implication here is that many individuals will work in low-wage jobs, which will amount to deficits when trying to make ends meet.
In 2016, employment in West Central Missouri was over 81,700. Employment in the region fell 0.6 percent from 2015 to 2016, losing 450 jobs. From 2011 to 2016, the region averaged 0.3 percent annual employment growth, compared to 1.3 percent for Missouri. During the same timeframe, health care and social assistance added 696 jobs, the most among all industries in the region. Employment growth stalled in recent years as the industry lost over 240 jobs combined in 2015 and 2016.

The executive order also takes aim at the food stamp program, often referred to as Supplemental Nutrition Assistance Program or SNAP. Entitlement programs, like SNAP and Medicaid, saw surges in enrollment during the country’s Great Recession. More than 41 million people receive food stamps. According to the Center for American Progress, of people in households that receive food stamps or SNAP and have at least one non disabled adult, 58 percent are employed, and 82 percent worked in the year prior to or after enrollment.

Agencies like the Department of Agriculture, which administers SNAP, and the Department of Housing & Urban Development (HUD), which offers subsidized housing, have 90 days from April 2018 to submit a list of recommendations and policy changes to their work requirements per the executive order. HUD already has plans to increase rent on millions receiving federal housing assistance.

Section 1115 Medicaid Wavers provides states an avenue to [test] new approaches in Medicaid that differ from federal program rules. As of April 27, 2018, Missouri is one of more than a dozen states approved for a Medicaid work requirement waiver by the Center for Medicare and Medicaid Services (CMS). Most of these Republican-lead states, like Missouri, have received approval to add the work mandate.