In Montana, a man named James, who relies on government-subsidized health insurance, has been trying to juggle his job while maintaining his old car, using it to make sandwiches after working long hours. He decided only to share his middle name for fear of losing his health coverage or being wrongfully accused of Medicaid fraud. For some weeks, he found employment in food service positions within addiction treatment programs, and his boss seemed supportive.
With a chuckle, James claimed, “I’m a good worker.” He depends on Medicaid for necessary prescription medications that help him manage his life, curbing his desire for alcohol and treating conditions like bipolar disorder and insomnia.
Despite his efforts, James hasn’t qualified for the program recently due to an increase in his working hours and a raise of about $1, which puts his annual income at around $21,000—just over the eligibility limit.
“Fudging Numbers”
Even with this modest raise, James finds it hard to cover daily expenses, such as car maintenance and phone bills. The costs of his medications, including those that help him sleep, have become burdensome, particularly for someone who’s supposed to be earning enough to afford healthcare. “I only saw one option,” he noted. “Fudge numbers.”
He hasn’t reported his new income to the state, directly challenging the Republicans in Congress who say adding labor requirements to Medicaid is necessary to curb waste and fraud. James insists he’s not contributing to that issue, unlike those who might take advantage of the system.
A Confusing System
Medicaid is essential for providing healthcare to over 70 million people in the U.S., yet experts suggest that actual fraud among recipients is quite rare. In fact, research indicates that many eligible individuals aren’t even enrolled. The complexity of the system is so overwhelming that nearly two-thirds of Medicaid enrollees were employed last year.
Transitional programs from Medicaid can sometimes lead to alternative low-cost health insurance options, but gaps in coverage can create issues, as seen in James’s case, leaving him and many like him trapped in a cycle of underemployment and health care inadequacy.
Dark Options
James identifies as a patriotic individual who believes government resources shouldn’t be misused by the lazy. He somewhat aligns with the Republican viewpoint advocating for work requirements associated with Medicaid. “I don’t want to be a scam. I don’t want to die. Those aren’t just two options,” he admitted, grappling with the reality of needing to deceive the system for the sake of his health.
The new legislation signed by Trump complicates things further by imposing stricter work or educational criteria to qualify for Medicaid, along with requiring proof of employment every six months. Ben Somers, a health economist, expressed concerns that these changes will particularly harm hard-working individuals who rely on these support systems.
Initially, James resisted accepting a pay raise, fearful it would jeopardize his Medicaid coverage. He had recently started reporting on his recovery program and found it financially untenable to remain there. If he couldn’t increase his savings, finding stable housing after graduation would likely elude him.
A General Dilemma
This predicament isn’t unique to James; many find themselves losing Medicaid suddenly when they start making a bit more income—a phenomenon dubbed the “cliff of profit.” Pamela Herd, a researcher studying government assistance, noted the absurdity of someone losing all benefits over a mere dollar raise.
While policies like continuous eligibility could help maintain coverage for low-income workers, recent legislative changes have restricted these measures, putting more people at risk of sudden ineligibility based on income fluctuations.
James is not actively breaking any rules, yet Montana has imposed new reporting requirements for income changes. He reflects on how far he’s come—about a year ago, he struggled to function and was unable to eat without alcohol. His past includes painful memories and troubling experiences related to his addiction.
Now, having graduated from his treatment program, he and his girlfriend are looking for affordable housing and he’s taking classes to become a licensed addiction counselor, hoping to leverage his experiences to help others. Yet, the shadow of potentially losing Medicaid looms over him as he continues to progress. “Every time I get an email, I’m afraid it’s going to inform me that it’s gone,” he shared.
