Why work requirements won’t work


April 26, 2018

28-year-old “Jerry” is a white male, divorced with two sons, and a high school dropout. He began drinking alcohol and using marijuana when he was 14, and by age of 19 had expanded his addiction to include heroin, pills, and cocaine.

He’s failed twice to complete inpatient treatment programs, one of which cost his family $30,000 as he had no insurance at that time. He has relapsed twice, the last time costing him his job and his marriage.

“Jerry” recently stood before a district court judge in Opiate Recovery Court in Harford County, Maryland, pleading guilty to three driving violations, a petty theft charge, and possession of heroin and un-prescribed medications. Having recently enrolled in Medicaid, he soon will begin a court-ordered, intensive outpatient treatment program at a local hospital. He will be required to complete 12 hours of individual and group counseling for several months, have frequent urine tests that show no drugs, take his medication as directed to suppress his drug cravings, and take advantage of support services for him and his family.

“Jerry” is not actually a real person in his own right, but is a composite of two very real individuals under the care of Don Mathis, a case manager serving three drug courts in Harford County, Maryland. (Full disclosure: Mathis, a board member of Doctors for America, also serves on the CHN Board of Directors.)

As you probably know if you follow the news (including the Voices for Human Needs blog), Congress, President Trump and many states are considering adopting “work requirements” as a condition of receiving certain assistance, including SNAP and Medicaid, which covers tens of thousands of Americans who are receiving treatment for substance abuse. We’ve written in the past about why work requirements are not only bad public policy, but actually a Trojan horse for kicking people off of programs such as Medicaid and SNAP, and “saving” considerable dollars by ending aid to people who need it.

In 2016, 1.9 million nonelderly adults in the U.S. had an opioid addiction, according to the Kaiser Family Foundation. Medicaid covers four out of every ten nonelderly adults with opioid addiction, and those with Medicaid were twice as likely as those with private insurance or no insurance at all to have received treatment in 2016.

Work requirements already have been approved by the Trump Administration in Kentucky, Arkansas and Indiana, and are anticipated in other states. (And a shout out to our friends at Families USA, who are doing a great job charting which states are seeking waivers.)

But to Mathis, “Jerry” is Exhibit A as to why work requirements don’t work.

Mathis explains that without Medicaid, “Jerry” would not be able to get his treatment and other help. “While he’s starting the necessary steps to get sober and reduce the effects of opioids on his brain, he is not remotely ready or capable of finding and keeping a job,” Mathis explains. “His recovery will progress in incremental stages and his major focus has to be on those activities and responsibilities of his court-ordered treatment. With Medicaid, Jerry has a real chance of getting well and eventually being employable. If a work requirement was to interrupt his treatment schedule and mandatory sessions, he almost certainly will relapse, return to his opioid use, engage in risky and illegal behaviors and die from an overdose.”

And “Jerry” is not an exception to the rule, but rather is quite representative of the participants Mathis works with in Harford County’s Opiate Recovery Court. Over the past 16 months, Mathis has served as case manager for 164 defendants who have appeared before the court. He says 115, or about 70 percent, received or are still receiving Medicaid, essential for their treatment and recovery.

He further estimates that fewer than 8 percent of participants have jobs when they enter the program. But even those jobs are at risk because of a number of factors, Mathis notes: “Often, as a result of their program requirements, individual and group counseling sessions, frequent urine tests, some time in county detention center, probation meetings, other court requirements such as community service hours, verified attendance at Narcotics Anonymous and/or Alcoholic Anonymous meetings, these people lose their jobs.”

It’s not just the many and perhaps seemingly insurmountable hoops people must jump through that make work requirements just a bad idea. It’s also that they interfere with one of the very first rules that people with addiction face – focus on your own addiction before all else.

This is a rule Mathis knows first-hand.

Thirty-two years ago, Mathis began his own recovery from alcohol and drug abuse.

“Then, as now, the message for people in the early stages of treatment and recovery is the same –focus only on your recovery,” Mathis says. “Don’t start any new romantic relationships; don’t start college or training programs; stay away from negative people, places, and things; start getting well and start healing your addictive brain.”

In the 12 months ending last September, 45,000 people in the U.S. fatally overdosed from opioids. The recent influx of fentanyl and synthetic opioids are increasing the overdose rate substantially.

Mathis fears the overdose rate will rise for every state that imposes work requirements.

“People need to get well before they can be expected to work,” he explains. “The road back to health and sanity after a life immersed in opioid and other substance disorders takes time, often years of inpatient, then outpatient, then sober living homes, then a sustained recovery plan. To disrupt this sequence of healing and recovery by mandating an unrealistic work requirement will lead to deaths that could be avoided, create more bureaucratic morass, fail the local labor market needs, and increase health and criminal justice costs.”


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