When you get as sick as I did, you realize how critical health coverage is for everyone

I’ve recently returned from a four-month hospital stay, the cause of which was an infection of unknown origin. It shut down most of my organs and put my life in jeopardy. Miraculously, I recovered. The illness was catastrophic and unexpected, and could strike anyone, no matter their race, income, or whether they have underlying health problems.

I had excellent insurance coverage — traditional Medicare and a fine supplement from my employer of nearly 30 years. One thing my family did not have to worry about was paying the bills, which totaled some $3.6 million before insurance whittled them down and paid almost all of them.

As I’ve gotten back to writing, I’ve thought about the inequities in American health care and the families who are not as lucky as we were. A recent Commonwealth Fund study found that 46 percent of working-age adults could not pay an unexpected medical bill of $1,000 within 30 days. Thirty-nine percent of those with individual insurance reported they could not pay such a bill. What will happen when the bill collectors start hounding them, as they surely will? “A large share of people simply don’t have the savings to cover an unexpected medical event if they have a high-deductible plan,” Sara Collins, a vice president at the Fund, told me. “It’s no wonder that we continue to see high rates of people with medical debt.”

One thing my family did not have to worry about was paying the bills, which totaled some $3.6 million before insurance whittled them down and paid almost all of them.

That led me to consider the changes being made in some state Medicaid programs, which may result in thousands of poor Americans losing coverage. Most people at risk of losing coverage wouldn’t be able to pay their medical bills if a similar infection struck them.

And that, of course, brings up America’s still unresolved questions: Is health care a right or a privilege? Should poor people get medical care only if they have a job or engage in community service? At the moment these questions are not part of the national health care conversation, but they should be.

Four states — Indiana, Arkansas, Kentucky, and now New Hampshire — have gotten federal approval for imposing work requirements on Medicaid recipients. In New Hampshire, for example, adults from 19 to 64 who are currently on Medicaid will have to participate in 100 hours a month of what the state calls “community engagement activities.” That’s a big, fat euphemism for work, job training, or community service, now prerequisites for getting coverage for maladies large and small.

Work requirements are a money saver for the states that have passed legislation authorizing them. Joan Alker, executive director of Georgetown University’s Center for Children and Families, is blunt: “Basically it’s a way to reduce Medicaid enrollment.”

For current recipients who can’t meet those requirements and are kicked off the rolls, states will be able to spend less money for their medical care, one of the objectives of New Hampshire’s new rules. As Gov. Chris Sununu has put it, “Work requirements help lift able-bodied individuals out of poverty by empowering them with the dignity of work and self-reliability, while allowing states to control the costs of their Medicaid programs.” In other words, if residents on Medicaid can’t find work or participate in training or community services, that could mean no health benefits and no care. Medicaid programs will have fewer bills to pay and states will save money.

Is it okay for the government to subsidize employers for providing health insurance, but it’s not okay for state governments to subsidize health care through Medicaid programs so poor women can get coverage?

A few states mainly in the South are considering changes that would make it even harder for low-income moms to obtain Medicaid. Alabama, for instance, did not embrace Medicaid expansion, a choice states could make under the Affordable Care Act. It also has the country’s strictest Medicaid eligibility standards, along with Texas. Only those making 18 percent of the poverty level or less — $3,740 annually for a family of three or about $312 a month — qualify. However, if these people find a job and work 35 hours a week (or 20 hours if they care for a child under age 6), as the state has proposed, they lose their Medicaid benefits. That’s because they would then make too much money to still qualify for the program, but not enough to pay for private insurance. Alker calls it a Catch-22.

Requiring that people work in order to qualify for medical care, a basic right in other developed countries, is cruel, especially when we don’t require millions of spouses of workers covered by employer-provided insurance to work. Perhaps the worker in the household is enough to make the connection to the workplace. But that gets into the thorny territory of work-based health coverage, the bedrock of the U.S. system.

If someone in the family works for an employer that offers coverage, usually the husband, then the spouse and kids usually can get coverage too. It has been that way since the end of World War II and has resulted in a federal tax break of $287 billion to employers that offered health insurance in 2017. Coverage available to spouses of covered workers and their kids is not contingent on the spouse (historically mostly women) obtaining a job or doing community service. In 2016 nearly 37 million women ages 18 to 64 were married and half of them had employment-based coverage through someone else, presumably a spouse, according to Paul Fronstin, director of research and education at EBRI.

We don’t ask if requiring poor women in Alabama to work to get medical care creates a double standard for America’s health insurance. Is it okay for the government to subsidize employers for providing health insurance, but it’s not okay for state governments to subsidize health care through Medicaid programs so poor women can get coverage? Either way, imposing work requirements on poor women means they will almost certainly face an uphill battle in getting the care they need. For anyone facing the kind of medical ordeal I narrowly survived, that’s a terrifying prospect indeed.

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care blog.