I recently watched a video of Seema Verma, the current Administrator of the Centers for Medicare and Medicaid Services, outlining her vision for Medicaid. She spoke of the need to give states greater flexibility in administrating their Medicaid programs, a change that we at the Quality Institute support.

She also touched on a question I have often thought about: Should the government be required to provide health care to all?

Or should health care be earned?

Verma made her position clear when she said this about Medicaid: “The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve able-bodied adults does not make sense.”

Atul Gawande, the surgeon and health policy thinker, explored similar themes in a recent article called, Is Health Care A Right?

The question is uniquely American. During World War II, to circumvent a national wage freeze and attract employees, American companies began providing health benefits. Ever since, health care has been tied to work. No other industrialized nation so strongly connects health care to employment.  This is the genesis of Americans viewing health care benefits as something “earned,” as opposed to a right.

But does it make sense from a policy standpoint?

As CMS tells states to consider imposing work requirements in Medicaid, let’s keep a few critical points at the forefront. In New Jersey, more than half (55%) of all the people covered by Medicaid are children. And nearly 20% are elderly or have disabilities.  Of the remaining 25%, half of them already are working.

They work in jobs that do not provide health insurance. Perhaps they work part time, or in a string of part-time jobs. Or they work full time in jobs with wages so low that purchasing health care is unrealistic. They may also have challenges around child care, transportation or criminal convictions. They may be full-time caretakers, or have a myriad of other reasons why they need Medicaid and aren’t working outside the home.

Interestingly, Verma also said we should celebrate able bodied adults by helping them “move up, move on, and move out.” Who could not agree? Yet sometimes what a person needs to move up, move on and move out is good health care. Having access to primary care, dental care and mental health care is the very first step toward feeling good enough to start that upward movement.

America is not and never will be The Netherlands.  We celebrate individualism and hard work. But let’s be honest in this discussion. We can embrace opposing values. We can believe people should earn what they receive. But we must also provide people with the fundamental supports they need to move forward.

Let the debate continue. In the meantime, I ask that we don’t dismiss the genuine and real struggles of people in New Jersey trying to make ends meet while also keeping themselves and their families healthy.