The Price of a ‘Culture of Work’: Who Is Left Behind?
When Iowa Governor Kim Reynolds signed a sweeping set of bills into law earlier this month, she declared it a return to the “intended purpose” for government assistance. One provision stands out for its sheer potential impact: ushering in new work requirements for Medicaid recipients. For nearly 171,000 Iowans—most of whom are low-income adults on the Iowa Health and Wellness Plan—the message is both simple and stark: work at least 80 hours per month, enroll in education or skills training, or risk losing health insurance. There are echoes here of welfare reforms from the 1990s, a policy direction that continues to haunt American safety nets.
The numbers tell a chilling tale. Nonpartisan analysis from Iowa’s Legislative Services Agency projects that some 32,000 eligible Iowans—more than the population of most Iowa towns—could lose health coverage. If the past is prologue, it’s worth recalling Arkansas’ 2018 experiment with Medicaid work requirements. As the non-profit Kaiser Family Foundation documented, nearly one in four non-exempt Arkansans lost coverage—not because they failed to work, but because navigating the bureaucratic red tape proved a near-impossible hurdle.
What does it mean for a single mother in rural Iowa, juggling two part-time jobs with unpredictable hours? For someone struggling with undiagnosed mental illness, unsure where to turn, let alone how to file monthly employment reports online? Those are the faces behind the statistics, individuals balanced on a razor’s edge between health and hardship.
Unintended Consequences: Medicaid, Hospitals, and Rural Iowa
Iowa’s move mirrors a broader trend among red states eager to prove their fiscal responsibility. The emphasis on a “culture of work” may sound appealing, but it fails to recognize the complexity of poverty and employment in the real world. Harvard economist Benjamin Sommers, who extensively researched work requirements, found that most Medicaid beneficiaries already work or have legitimate reasons they cannot. He writes, “Requirements don’t create jobs; they just create obstacles to coverage.”
Beyond that, critics warn of ripple effects across the state’s already fragile rural healthcare infrastructure. Rural hospitals, often operating on razor-thin margins, rely on Medicaid reimbursement. If even a fraction of those projected 32,000 Iowans lose coverage, the resulting payment shortfalls could threaten clinics and emergency rooms in communities where alternatives do not exist. According to the Iowa Hospital Association, uncompensated care has risen every time eligibility screenings have tightened—leaving rural facilities to pick up the slack without support.
There’s another risk: as coverage falls, public health suffers. The evidence from states with harsher requirements is sobering: higher rates of preventable illness, missed prescriptions, and delayed care. The people at risk are often working in low-wage, physically demanding jobs where access to healthcare is most critical—factory workers, food service employees, caregivers. Critics argue that taking away coverage doesn’t incentivize work; it merely makes poverty less survivable.
“Requirements don’t create jobs; they just create obstacles to coverage.” — Dr. Benjamin Sommers, Harvard School of Public Health
A closer look reveals a law with plenty of political muscle but scant evidence of actual benefit. The Center on Budget and Policy Priorities notes that administrators spend far more tracking compliance than the state saves. This is bureaucracy for bureaucracy’s sake, paid for in lives destabilized and communities frayed.
Opioid Funds, Transparency—and an Ominous Shift in Welfare Precedent
While headlines focused on Medicaid, a second significant law channels $56 million from opioid settlements into addiction treatment and prevention. This move, at least, aligns with Iowa’s dire public health needs. The state ranks among the hardest hit by the opioid epidemic in the Midwest, and experts like Dr. Brian Torner at the University of Iowa call the new resources “badly overdue.”
Yet, even that accomplishment sits in the shadow of Iowa’s broader shift. Lawmakers passed an additional suite of measures to tighten open meetings and records compliance, hiking fines for public officials who flout transparency—needed affirmations, perhaps, that public process should not be closed off or hidden from scrutiny.
The overhaul of the state’s Research Activities Credit, converting it into an R&D tax incentive more closely linked to job preservation, reflects anxieties about economic transitions. The inclusion of clawback provisions for companies offshoring jobs is, at minimum, a nod to the realities faced by Iowa’s working families. Still, these economic adjustments pale next to the looming fallout from stripping healthcare away from thousands.
Cynics—perhaps rightly—view the work requirements as part of a national conservative project to recalibrate the very notion of social insurance. Under the guise of promoting self-reliance, these laws set a disturbing precedent: if you cannot work enough, you don’t deserve healthcare. Progressives argue that this runs counter to the fundamental American promise of security in times of need. By making Medicaid harder to access, Iowa is both toughening eligibility and hardening society’s edges—at a time when so many need compassion.
A Pew Research Center survey found that the vast majority of Americans support Medicaid as a safety net. The notion that it must be whittled down to only the “truly deserving” is itself a political construction, not an economic or moral necessity. Governors may insist that the policy reflects public values, but whose values—whose lives—are elevated in the process?
Looking Forward: Iowa as Bellwether
As Washington evaluates Iowa’s waiver request, the fate of thousands rests not just on hours worked but on a deeper debate about what kind of society we wish to be. Historical parallels abound: in the early years of welfare reform, similar work mandates consistently left women, minorities, and rural Americans more vulnerable, not less. The lost coverage in Arkansas, for instance, was not paired with subsequent spikes in employment rates—a finding published in the New England Journal of Medicine.
Will Iowa learn from these lessons, or will it march forward, remaking Medicaid in a manner that privileges ideology over evidence? Policies that treat poverty as a product of individual failing have never succeeded in solving it. The most successful anti-poverty programs in U.S. history, from Social Security to Medicare, were universal and straightforward—not swaddled in red tape and punitive oversight.
The real test is still to come. As Iowa’s version of Medicaid work requirements faces federal review, you have to wonder: are we upholding the social contract, or tearing it down thread by thread? The answer will shape not just who gets coverage in Iowa, but how states across the country approach public health, economic uncertainty, and the moral boundaries of shared responsibility.
