By JAMILA MICHENER and JULILLY KOHLER-HAUSMANN JUNE 28, 2017
This would tie lifesaving health care benefits to government procedures that force people to submit to degrading invasions of privacy. Of all the ways to help Americans with drug problems, threatening their Medicaid eligibility is among the worst options.
Much attention has rightly focused on the Senate bill to reduce federal Medicaid spending by as much as $772 billion over the next decade, which would result in 20 million fewer enrollees. But budget cuts are not the only way to weaken Medicaid and limit access to health care.
Indeed, President Trump’s insistence on giving “our great state governors the resources and flexibility they need with Medicaid” does just that. While flexibility has at times allowed some states to expand services, others like Arizona, Kentucky and Maine are now attempting to impose conditions, such as time limits or work requirements, that would shrink the program. Because these reforms are more palatable than draconian cuts, they can easily slip beneath the radar and quietly imperil Medicaid’s long-term viability.
It may seem like giving states the power to drug test Medicaid recipients is reasonable. Governor Walker’s administration claims that doing so will “help people get healthy so they can get back in the work force.” And drug screening shouldn’t be a problem for people who are abiding by the law, right?
Yet the history of public assistance policies shows that measures like Governor Walker’s can catalyze a vicious cycle of stigmatization and program retrenchment. Traditional cash assistance programs lost popularity as they incorporated practices like fingerprinting, surveillance, time limits and work requirements, and as political rhetoric linked the program with racist representations of African-American mothers.
In Wisconsin, where 33 percent of Medicaid beneficiaries are black or Hispanic, the spectacle of calling for drug testing marks people who rely on the government as inherently suspect. When this happens, the public becomes less willing to support such programs and people become less willing to use them, even in times of desperate need. All of this makes the program increasingly vulnerable to further cuts and eventual dismemberment.
While no state has been allowed to drug test Medicaid beneficiaries, politicians have initiated similar policies with Temporary Assistance to Needy Families. The results are resoundingly clear: Drug testing is costly, invasive and ineffective. In recent years, seven states with drug-testing programs for T.A.N.F. have spent over $1 million, only to find that in six of them, fewer than 1 percent of beneficiaries tested positive, compared with about 10 percent of the general population.
There is no reason to believe that Medicaid recipients are more likely to abuse drugs than the general population. And the risks of drug testing in a health care program are unique. People in need of substance abuse treatment may respond to this policy by avoiding Medicaid altogether. This is a dangerous possibility at a time when more Americans are dying of drug overdose than in car accidents.
In fact, one of the most effective strategies for mitigating the harms of drug use has been the Medicaid expansion under the Affordable Care Act, which dramatically increased the number of people with health coverage and required that states provide substance abuse treatment.
Under Wisconsin’s proposal, people who use drugs will not automatically lose benefits, but they will be forced to undergo screening, testing or treatment, or all three, to maintain eligibility, which risks driving people from the program. Given the current opioid crises, states should not erect any barriers to health care access or treatment.
And drug testing doesn’t hurt only people who use drugs. Associating all Medicaid beneficiaries with a scorned social group, drug users, poses a danger to everyone’s health. Such stigmatization can prevent people who are eligible for assistance from using it and inhibit those in need from seeking medical treatment.
Drug testing also jeopardizes our democracy. For many of the more than 70 million Americans who rely on Medicaid, state-run programs, like Wisconsin’s Badgercare, are their closest contact with the state. This is how people learn firsthand about government. For example, Medicaid recipients are more likely to participate in elections and other forms of politics when they live in states that have expanded coverage or that offer a wider scope of benefits, like dental and vision services. The opposite is true for beneficiaries who live in states that have restricted benefits and services.
1COMMENTMany Medicaid beneficiaries already feel stigmatized. A woman we met in Chicago was an uninsured diabetic in her early 60s who desperately needed health care. But she was treated so badly when she applied for Medicaid that she walked away.
Drug testing threatens a huge portion of the country. Twenty percent of Americans already depend on Medicaid, and millions more are only one bad break away from the prospect of urinating in a cup to prove that they deserve health care.
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Jamila Michener is an assistant professor of government at Cornell, where Julilly Kohler-Hausmann is an assistant professor of history.