Saturday, April 8, 2017

Work requirements for Medicaid expansion would affect relatively few people; most are already working or would be exempt

By Melissa Patrick
Kentucky Health News

Requests by Kentucky and other states to require "able-bodied" Medicaid beneficiaries to work or pursue work still haven't been approved, but the expectation is that they will be soon.

"We are still in negotiations with CMS on our 1115 Medicaid waiver and feel optimistic about the ultimate outcome," state Cabinet for Health and Family Services spokesman Doug Hogan said in an e-mail.

Medicaid Commissioner Stephen Miller told Lisa Gillespie of Louisville's WFPL Radio that he expects to know about the changes by the end of June, with expectations that it will be approved, and that the goal is to put the new system in place Jan. 1, 2018.

Kentucky's waiver proposes that the state be allowed to charge small, income-based premiums and would require "able-bodied" recipients to either work, volunteer or take job training, gradually increasing in hours to a maximum of 20 hours a week after one year, among other things.

Under the Obama administration, the U.S. Department for Health and Human Services said such a provision does not fit the program's goals to promote health coverage and access.

But under the Trump administration, HHS officials sent a letter to the nation's governors "urging states to alter the insurance program for poor and disabled people by charging them insurance premiums, requiring them to pay part of emergency-room bills and prodding them to get jobs," notes Amy Goldstein of The Washington Post. Support for work requirements was also included in the Republican health-reform bill that did not come to a vote.

What states have applied for work requirements?

Kentucky, Indiana, Pennsylvania and Arizona have waiver requests pending that include work requirements. All but Indiana's would require a certain amount of work, typically 20 hours, or another approved activity, and does not seek a work requirement.

Indiana's request would require a referral to a work-search program. The Hoosier State also has pending a request for renewal of its earlier waiver, which was drafted with the help of a consultant, Seema Verna, who is now head of the Centers for Medicare and Medicaid Services. She also helped draft the Kentucky request and has recused herself from its consideration.

Indiana, Montana and New Hampshire have a voluntary work-program referral, but only for people covered by expanded Medicaid. Arkansas is seeking changes to its waiver to include a work requirement, but has not submitted a proposal.

Kentucky's proposed requirement would apply only to people covered by the Medicaid expansion and would not apply to people who are judged to be "medically frail" or are primary caregivers.

Policy arguments for and against

Work requirements would be a fundamental change in the 52-year-old Medicaid program, MaryBeth Musumeci of the Kaiser Family Foundation writes in an issue brief that looks at the work rules proposed by each of the states in their Medicaid waivers, and considers key policy issues around such request.

Arguments for work requirements center around whether a person thinks Medicaid is a "cash welfare program or one that provides health insurance," Musumeci writes. However, changes in the program since it was created in 1965 have separated it from the welfare system. For example, eligibility is no longer linked to whether a person is on food stamps, and the Patient Protection and Affordable Care Act expanded Medicaid to those who earn up to 138 percent of the federal poverty line, moving beyond pregnant women, seniors or those with disabilities.

Proponents of work requirements say being in the workforce will help people become healthier, and say Medicaid expansion has been a disincentive for some members to work, partly because a job could raise their income above the 138 percent limit. However, a recent analysis of Ohio’s Medicaid expansion found that most expansion enrollees who were unemployed but looking for work reported that Medicaid enrollment made it easier to seek employment.

Even supporters of the requirements have concerns, Musumeci reports. Some fear they would discourage people from signing up for Medicaid, steering them to emergency rooms for routine care. Others are concerned that the requirements will only be effective when the economy is strong.

Opponents of the work requirements say that health insurance is necessary for good health, which is a pre-condition to work, and that these requirements create a barrier to health coverage, Musuimeci writes.

Many adults on Medicaid already work

Most Medicaid beneficiaries are working already, and those who aren't would likely be exempted under the expected waiver.

"Nearly eight in 10 Medicaid adults are in working families, and most (59%) are working themselves without being required to do so as a condition of coverage," Musumeci reports.

The Kentucky Center for Economic Policy reports that "over half of all Medicaid eligible Kentuckians who gained health insurance between 2013 and 2015 held a job," according to the Census Bureau's American Community Survey. The vast majority of those gains came from Medicaid expansion.

Most working Medicaid recipients in low-wage jobs, and most are in jobs that don't offer health insurance, such as farming or food service, Musimeci reports.

"Even when excluding Supplemental Security Income beneficiaries, most Medicaid adults who are not working report a major impediment in their ability to work, with 35% citing an illness or disability that prevents them from work," she writes. "Others are taking care of home or family (28%), in school (18%), looking for work (8%), or retired (8%)."

In conclusion, Musumeci writes, "Conditioning Medicaid eligibility on meeting a work requirement likely would apply to a small number of people, given that most Medicaid beneficiaries who can work already are doing so."

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