Peggy Huppert retired in 2023 following a 43-year career with Iowa nonprofit organizations, including the American Cancer Society and NAMI (National Alliance for Mental Illness) Iowa. She is also a long-time progressive political activist.

It does not surprise me, but disappoints me greatly, that the Iowa legislature is poised to adopt a policy requiring “able bodied” Medicaid recipients to work at least 80 hours a month in order to stay enrolled.

This is nothing new. Some Republicans tried to implement this in Iowa during Donald Trump’s first administration. As the head of NAMI Iowa, I successfully helped fight this legislation for four years before a reprieve during the Biden administration. Now, with an even larger majority in both the Iowa House and Senate, encouragement from our governor, and a green light from the new Trump administration, there is nothing holding the Republican majority back.

As a mental health advocate and family member of loved ones with serious mental illness, I would like to see the phrase “able bodied” (just like “It’s all in your head”) permanently retired from our lexicon.

Who defines able bodied? The phrase implies one’s physical body is healthy enough to work. But you can’t tell by looking at someone if they are suffering from a serious medical challenge. And it is not a static condition.

People with serious mental illness are sometimes capable of work and sometimes not. That capability is not predictable or reliable. Medicine will work, and then it won’t. A new drug could take six to eight weeks to take effect. If it doesn’t work, you have to start all over again. (And then your insurance company might decide they aren’t going to cover it anymore.) There are many ups and downs.

The stated goal of Senate File 615 is to “reduce the dependence of low-income Iowans on public assistance programs through efforts that advance economic stability and mobility.” Supporters love to talk about the “dignity of work.” There are lofty claims about the boost to one’s mental health that comes with work.

Yet on a practical level, this legislation has very little to do with advancing economic stability and mobility. If Republican legislators really wanted to do that, they would raise the minimum wage, provide better job training programs, require that employers offer health care benefits, boost affordable housing and day care, and address transportation challenges. Yet they are doing few of these things. Instead, they are saying, “You’d better find yourself a job.”

There are so many unanswered questions that the majority party (or the governor) does not seem bothered by. For example:

• Where will these tens of thousands of Iowans work, and what they will do? Most Medicaid expansion recipients do work, out of pure economic necessity. If good jobs they were able to do were readily available, they would already be doing them.
• If they have intellectual or medical challenges (which many Medicaid recipients do) but do not qualify for federal disability status, will they receive proper support and accommodations? Have any potential employers agreed to provide these things?
• For the many recipients without reliable transportation, how will they get to and from work, especially in small towns and rural areas where public transportation is virtually non-existent?

And then there is the reporting issue. Recipients must provide documentation of their work on a schedule and in a format mandated by the state. 

In Arkansas, which had a disastrous run at this in 2018, the problem wasn’t so much about people working as it was about reporting. They required it to be done weekly, online, during a certain time frame. It could not be done on a smart phone. As you might imagine, that caused a lot of problems, with very little help available from the state.

Subsequent research found that most recipients didn’t even know they were subject to the requirement, let alone understand how to comply. They discovered they had lost coverage when they went to fill a prescription or for a medical visit.

Because of these rigid requirements and onerous red tape, one in four Arkansas recipients targeted by the effort (around 18,000 people) lost coverage in the first seven months. What’s more, the percentage of Medicaid recipients who were working didn’t substantially change! Officials at Iowa’s Department of Health and Human Services claim that won’t happen here, yet have offered few clues about how they will do it better.

Finally, there is the issue of cost to the state to implement versus any economic benefit. When similar ideas were floated years ago, the Department of Human Services (later reorganized as HHS) estimated that implementing work requirements would be costly, to the tune of tens of millions of dollars.

This year, HHS officials refuse to say exactly how much it will cost. Some have suggested the state could implement the program with extra money lying around. But it’s all so vague and murky that the nonpartisan Legislative Services Agency stated in the fiscal note on Senate File 615 that the LSA “has not received a response to multiple requests for information from the HHS.”

Despite Governor Kim Reynolds’ attempts to make us believe otherwise, there is no doubt that the state will bear a hefty cost, with virtually no return on investment, if their goal is just to get people working, to make them “less reliant” and boost their mental health.

However, if the state’s goal is actually to kick people off Medicaid for failure to work—or more likely, failure to report the work they are doing—that will save the state money. And that, my friends, is the real goal.

Perhaps the most alarming thing about this bill is the provision that says Iowa would automatically end its Medicaid expansion program if any future administration rescinds the state’s waiver implementing work requirements. That would immediately kick nearly 200,000 Iowans off their health care coverage. It’s a warning to any future (Democratic) administration: don’t mess with red-state Medicaid policies. It is unheard of and unconscionable.

We should remember that Medicaid is not “welfare.” It is health insurance for low-income and disabled citizens. There is no direct benefit to recipients other than a chance to receive timely and appropriate health care. 

Any fraud in the system is on the part of providers, not recipients. Most adult recipients between the ages of 18 and 64 who are not caregivers have chronic health issues. Despite that, the overwhelming majority of them (around 90 percent!) work at least part time. If we expect people to work, then the last thing we should do is take away their health insurance. That’s just common sense.

So what is driving this bill? First and foremost it’s an ideology that worships the value of “hard work,” believes most recipients of any kind of government assistance are lazy, worthless and not trustworthy, and aims to punish them.  That same ideology is driving similar efforts like insisting that SNAP recipients only purchase “healthy” food and drinks with their benefit. What is “healthy,” and who is “able-bodied,” is in the eye of the beholder.

Second is the current perceived imperative to cut overall government spending at the national level in order to afford pet projects and tax cuts for billionaires. U.S. House Republicans approved a budget blueprint in February that calls for a reduction of $880 billion in Medicaid spending. Nearly everyone agrees that cut cannot be met by eliminating “waste, fraud, and abuse.” Reductions in programs, coverage or provider reimbursements will be necessary—and perhaps all three.

The Medicaid expansion program that most states eventually implemented as part of the Affordable Care Act has provided life-saving health care coverage for millions of Americans who previously didn’t qualify. That is now on the chopping block. Many are convinced that the real goal of all these state-based efforts is to eliminate Medicaid expansion.

Some Iowa legislators have alluded to that, saying Iowa can just “go back to the way things were.” So, the “good old days” when “indigent” Iowans from 98 counties had to go to Iowa City for care at the University of Iowa Hospital and Clinics, and Polk County citizens went to Broadlawns, all for limited “charity” care. When cancer patients slept in their cars and camped in Iowa City parks because they couldn’t afford lodging while going through chemo or radiation. When people with serious mental illness just didn’t get care at all unless they got so bad they ended up in a state institution. When many hospitals, especially rural ones, were choking on debt from uncompensated care. Yes, those good old days.

One thing we are learning in this new era of political shock and awe is “That could never happen” could, and probably will, if politicians think they can get away with it. The question is: are we going to let them?