As Congress considers instituting work requirements to maintain eligibility for Medicaid, it is illustrative to examine an effective model for how such requirements have been implemented in New York City to maintain eligibility for the federal cash welfare program Temporary Assistance to Needy Families (TANF).  Proposals to mandate work requirements as a condition of receiving social service benefits are too often debated on ideological grounds and ignore the reality of how such programs can be implemented to move recipients towards employment.  What are reasonable work requirements and how can states develop programs that are effective at moving individuals toward employment?  The goal for mandating work requirements as a condition of receiving Medicaid should not be to reduce Medicaid rolls per se but to assist individuals in seeking private employment so that they can better support themselves and thereby not require the Medicaid benefit.  What we do not want is a bureaucratic process where Medicaid recipients churn off and on the rolls merely because they did or did not comply with an administrative process. What we do want is to provide a path to self-sufficiency and independence.

The aim of work participation requirements for any benefit program is to create motivation for able-bodied individuals to achieve their highest level of vocational potential. Without work requirements, benefit recipients can become too dependent on public assistance. If work activities are wholly voluntary, then many people may be unmotivated to work. The challenge is to create fair and reasonable work requirements for those who are capable of work. If someone were seriously ill and unable to work, it would be unreasonable to expect them to meet a work requirement. The questions are how to make individual determinations fairly and accurately; who should make those determinations; and based on what medical evidence? The issue for each applicant is not just whether he or she has a medical disorder, but whether that disorder prevents the individual from working, either temporarily or permanently.

In the fields of psychology and medicine, the concept of “secondary gain” defines motivations for developing or maintaining illnesses. These might include financial benefits (such as disability payments), time off from work, and increased attention and caretaking by being in a dependent role (preferring dependency to self-sufficiency).  Even when an illness is real, as is usually the case, the individual may exaggerate its impact on their functioning.  In some extreme cases, the individual is malingering, meaning they are lying or making up symptoms that do not actually exist.  Public assistance, whether in the form of TANF, Medicaid, or food stamps (benefits from the Supplemental Nutrition Assistance Program, or SNAP), can represent an important secondary gain.  For this reason, it does not make sense to allow individuals to voluntarily decide if they can or should work, which is why work mandates are useful extrinsic motivators to encourage people to work.

New York City has implemented a fair and reasonable work mandate for TANF that we believe is an excellent model for how work requirements can be implemented for Medicaid.  Initiated during the Rudolph Giuliani administration (when one of us, Anthony Coles, was Deputy Mayor for Planning) and continued through subsequent mayoralties, New York has instituted a customized assistance model for welfare recipients, which determines their employability and provides employment services accordingly. 

This model was first instituted for people with serious substance abuse disorders, where we found that the majority were deemed employable after 60 to 90 days of treatment.  In other words, these individuals were temporarily exempted from the work requirement while they received intensive treatment and then were engaged in work activities while they were concomitantly in less intensive treatment.  Studies demonstrate that this program model was very effective at improving both substance abuse outcomes (based on toxicology results and longer time in treatment) and employment outcomes over one year.  Treatment plus work was a significant improvement over treatment alone.

Given the success of the customized assistance model, the New York City Human Resources Administration implemented a similar program model for welfare recipients with medical and/or psychiatric disorders.  The Wellness, Comprehensive Assessment, Rehabilitation and Employment (WeCARE) program engages 60,000 welfare recipients per year, representing at least one fifth of the welfare population in New York City.  These are all individuals who say that their illness represents an obstacle to working.  As the WeCARE Program Director for the Bronx, one of us (Scott Wetzler) has considerable experience implementing the WeCARE program model in a fair, reasonable, and effective manner. 

Applicants for TANF benefits who self-identify as having a medical or psychiatric problem are referred for a WeCARE appointment.  WeCARE program staff then contact the participant to explain the purpose of the program and the consequences for non-attendance at the appointment.  While the benefits of program participation are emphasized and scheduling conflicts accommodated, the program makes clear that failure to attend might result in loss of benefits.  At the initial WeCARE appointment (which can be conducted either virtually or in person), our clinical staff (i.e., medical social workers) do a thorough interview and take a history of all the participant’s present and past illnesses that might affect employability as well as treatments they may be receiving.  We also review medical records.  Based on this comprehensive health assessment, our clinical staff make a functional capacity determination:

• The participant’s medical disorders are so severe and disabling that they are permanently unable to work and are eligible for federal disability benefits from either Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).
• The participant’s medical disorders are unstable such that they are temporarily unable to work, but after 90 days of treatment, they will become employable.
• The participant’s medical disorders do not prevent them from working, and with reasonable accommodations they are employable.

These functional capacity determinations are reviewed by physicians on our staff and if there is any uncertainty, then the physicians or psychologists conduct their own physical exams or mental health assessments to ensure accuracy.  Thus, these employability determinations are based on objective medical evidence, not on the participant’s subjective complaints or lack of motivation to work.  Only by implementing this kind of rigorous assessment can agencies effectively determine who is and is not capable of working.

Based on our WeCARE experience, we have found that the majority of participants are, in fact, employable.  For the TANF population in the Bronx, only 15 percent of our participants are truly disabled.  For these individuals, we collect medical documentation to make SSI or SSDI applications on their behalf.  It would be unreasonable to expect these individuals to work.  

We have also found that 40 percent of our participants are clinically unstable and temporarily unable to work.  Our case management staff refers these individuals to appropriate medical providers for treatment and monitors their adherence to treatment recommendations.  A majority of these individuals (constituting 25 percent of participants) are then deemed employable after a 90-day exemption.

Finally, another 40 percent of our participants have a medical disorder that still requires treatment but nonetheless are deemed employable at the outset. (The remaining 5 percent of recipients are deemed to be fully employable without any limitations and are therefore not enrolled in WeCARE.) When those employable at the outset are combined with the 25 percent who are employable after their illnesses have stabilized, 65 percent of those enrolled in WeCARE are deemed employable.  

For these employable individuals, we offer a wide range of services, including job search and placement, community service assignments where they engage in work-like activities (in preparation for competitive employment), and education and training leading to certification.  This schedule of employment activities is tailored to the client’s strengths, weaknesses, and goals and accommodates their medical disorders.  

When clients are in the employment track, we monitor timekeeping to ensure that they meet the work participation requirements (greater than 25 hours per week).  We find that 25 percent of our participants in the employment track are successful in obtaining competitive employment during their time in WeCARE with companies such as Amazon, Spectrum, and Star Hospitality and as home health care aides and security guards.  The positions are typically at or above a living wage. Even though the majority of employable clients do not in fact achieve full employment within six months, we find that they remain eligible for benefits because they continue to meet the work participation requirements.

Work mandates serve as an extrinsic motivator to get people to work, but once engaged, we have observed that WeCARE participants truly like the services provided and benefit from them.  However, as with any extrinsic motivator, some people will test the limits of the so-called punishment by falling out of compliance with the participation requirements, in which case they go through a conciliation process with an Administrative Law judge.  Were this program completely voluntary or were there not such an enforcement process, we doubt that most people would have participated.  This is why the work requirement process must have real teeth and not allow for continuous churning on and off the rolls.

While the Medicaid population is not identical to the TANF population, this experience suggests that the vast majority of people on Medicaid are employable (and many are already working).  Given the potential passage of legislation requiring work participation as a condition of Medicaid eligibility, we think that the WeCARE program model represents a fair and reasonable way to implement a work mandate.  It aligns incentives, leverages motivation, and provides support services that help people on public benefits to achieve their maximum functional capacity.  Ultimately, it encourages individuals to move from dependency on a government benefit to self-sufficiency, with the goal of creating a more complete and rewarding life.

Scott Wetzler, PhD. is a clinical psychologist and a Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine. He is Chief Executive Officer of University Behavioral Associates, which is the Bronx WeCARE contractor.

Anthony Coles is an attorney and partner at DLA Piper. He previously served as Deputy Mayor of NYC from 1998 to 2001.