Expert Commentary

Does work improve health?

Research on the relationship between employment and health sheds light on the proposed rationale behind work requirements as an eligibility condition for Medicaid.


New guidance offered in January of 2018 by the Centers for Medicare and Medicaid Services outlines how states can impose work requirements as an eligibility condition for Medicaid, a federal health insurance program for the poor. The policy allows exemptions for some, including the elderly and disabled.

Brian Neale, director of the federal Medicaid office, says that a work requirement could be beneficial to health. “Productive work and community engagement may improve health outcomes,” he wrote in a January 11 letter explaining the policy to state Medicaid officers.

While the Trump administration bills the policy as an attempt at personal empowerment and improved health, some prominent Senators say it will push people off Medicaid, or add burdens and worsen recipients’ health. “Requiring poor families to jump through punitive administrative hurdles or pay more than they can afford makes it harder for them to access the care they need and are entitled to under Title XIX. Ultimately, this leads to poorer health,” they wrote in a letter to the Department of Health and Human Services.

So far, 10 states have submitted proposals for work requirements. Kentucky has already received approval. The decision has met opposition from health advocacy groups, including the National Heath Law Program.

As part one of a two-part research roundup on the latest negotiation of Medicaid’s role in society, we’ve gathered research on the relationship between employment and health. State reports highlight current employment characteristics of Medicaid recipients. These reports indicate how work requirements might make it more difficult for low-income people to get the healthcare they need to seek work. Part two of this roundup delves deeper into this issue, featuring research that complicates the link between employment and improved health.

Association between work and health

“Work as Treatment? The Effectiveness of Re-employment Programmes for Unemployed Persons with Severe Mental Health Problems on Health and Quality of Life: A Systematic Review and Meta-analysis”
van Rijn, Rogier; et al. Occupational & Environmental Medicine, 2016. DOI: 10.1136/oemed-2015-103121.

Abstract: “This systematic review and meta-analysis aimed to assess the effects of re- employment programmes with regard to health and quality of life. Three electronic databases were searched (up to March 2015). Two reviewers independently selected articles and assessed the risk of bias on prespecified criteria. Measures of effects were pooled and random effect meta-analysis of randomised controlled trials was conducted, where possible. Sixteen studies were included. Nine studies described functioning as an outcome measure. Five studies with six comparisons provided enough information to calculate a pooled effect size of −0.01 (95 percent CI −0.13 to 0.11). Fifteen studies presented mental health as an outcome measure of which six with comparable psychiatric symptoms resulted in a pooled effect size of 0.20 (95 percent CI −0.23 to 0.62). Thirteen studies described quality of life as an outcome measure. Seven of these studies, describing eight comparisons, provided enough information to calculate a pooled effect size of 0.28 (95 percent CI 0.04 to 0.52). Re-employment programmes have a modest positive effect on the quality of life. No evidence was found for any effect of these re-employment programmes on functioning and mental health.”

“Health Effects of Employment: A Systematic Review of Prospective Studies”
Van der Noordt, Maaike; et al. Occupational & Environmental Medicine, 2014. DOI: 10.1136/oemed-2014-102143

Results: “33 prospective studies were included, of which 23 were of high quality. Strong evidence was found for a protective effect of employment on depression and general mental health. Pooled effect sizes showed favourable effects on depression (OR=0.52; 95 percent CI 0.33 to 0.83) and psychological distress (OR=0.79; 95 percent CI 0.72 to 0.86). Insufficient evidence was found for general health, physical health and mortality due to lack of studies or inconsistent findings.”

“Association of Returning to Work with Better Health in Working-Aged Adults: A Systematic Review”
Rueda, Sergio; et al. American Journal of Public Health, March 2012. DOI: 10.2105/AJPH.2011.300401.

Abstract: “Eighteen studies met our inclusion criteria, including 1 randomized controlled trial. Fifteen studies revealed a beneficial effect of returning to work on health, either demonstrating a significant improvement in health after reemployment or a significant decline in health attributed to continued unemployment. We also found evidence for health selection, suggesting that poor health interferes with people’s ability to go back to work. Some evidence suggested that earlier reemployment may be associated with better health.”

“The Influence of Re-employment on Quality of Life and Self-rated Health, a Longitudinal Study Among Unemployed Persons in the Netherlands”
Carlier, Bouwine E.; et al. BMC Public Health, 2013. DOI: 10.1186/1471-2458-13-503.

Abstract: “A prospective study with 18 months follow-up was conducted among unemployed persons (n=4,308) in the Netherlands, receiving either unemployment benefits or social security benefits. Quality of life, self-rated health, and employment status were measured at baseline and every 6 months of follow up with questionnaires. … In the study population 29 percent had a less than good quality of life and 17 percent had a poor self-rated health. Persons who started with paid employment during the follow-up period were more likely to improve towards a good quality of life (OR 1.76) and a good self-rated health (OR 2.88) compared with those persons who remained unemployed. Up to 6 months after re-employment, every month with paid employment, the likelihood of a good quality of life increased (OR 1.12).”

“The Benefits of Paid Employment Among Persons with Common Mental Health Problems: Evidence for the Selection and Causation Mechanism”
Schuring, Merel; Robroek, Suzan; Budorf, Alex. Scandinavian Journal of Work, Environment & Health, 2017. DOI: 10.5271/sjweh.3675.

Results: “The between individuals associations showed that persons working ≥12 hours per week reported better mental health (b=26.7, SE 5.1), mastery (b=2.7, SE 0.6), self-esteem (b=5.7, SE 1.1), physical health (b=14.6, SE 5.6) and happiness (OR 7.7, 95 percent CI 2.3–26.4). The within-individual associations showed that entering paid employment for ≥12 hours per week resulted in better mental health (b=16.3, SE 3.4), mastery (b=1.7, SE 0.4), self-esteem (b=3.4, SE 0.7), physical health (b=9.8, SE 2.9), and happiness (OR 3.1, 95 percent CI 1.4–6.9). Among intermediate- and high-educated persons, entering paid employment had significantly larger effect on mental health than among low-educated persons.”

State reports

“Employment Status and Health Characteristics of Adults with Expanded Medicaid Coverage in Michigan”
Tipirneni, Renuka; Goold, Susan D.; Ayanian, John Z. JAMA Internal Medicine, December 2017. DOI: 10.1001/jamainternmed.2017.7055.

Excerpt: “Our findings have key implications for proposed work requirement policies for Medicaid expansion enrollees. First, more than half of Michigan enrollees were already working or students and thus would not be affected by work requirements. Second, most enrollees who were unable to work reported significant barriers to employment, such as poor health, chronic conditions, older age, or functional limitations. Work requirements could disrupt coverage for such vulnerable individuals who may not meet formal criteria for disability. Third, although those who were out of work reported better health and fewer functional limitations, the proportion of Medicaid expansion enrollees overall who were not working and possibly able to work if employment were avail- able remained small.”

“Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly”
The Ohio Department of Medicaid, January 2017.

Excerpt: This report looks at Ohio’s Medicaid Group VIII enrollees — that is, people who became eligible to enroll in the program after the state expanded the program in 2014. The expansion made most state residents with incomes at or below 138 percent of the federal poverty line eligible, whereas before recipients had to meet specific characteristics including disability or parenthood, and the threshold was 90 percent of the poverty line. “A majority of Group VIII enrollees reported that Medicaid has made it easier to secure and maintain employment. Among Group VIII enrollees who are currently employed, 52.1 percent reported that having Medicaid makes it easier to continue working (Figure 22). Among unemployed Group VIII enrollees looking for work, 74.8 percent reported that Medicaid makes it easier to look for work. For instance, one focus group respondent mentioned that she had a severe hernia and could not even get out of bed to go to work. After she enrolled in Medicaid, she had the needed surgery and could move around again. She was back to work and feeling much better. When asked what getting Medicaid meant, multiple survey respondents mentioned an improved ability to work when discussing their financial situation.”