Conservatives to Renew Push to Install Medicaid Work Rules

By Alex Ruoff

Several states could establish work requirements for their Medicaid beneficiaries this year, regardless of whether Congress approves them as part of repealing the Affordable Care Act, health policy researchers told Bloomberg BNA March 20.

Four states sought and were denied by the Obama administration waivers that would have allowed them to require some Medicaid beneficiaries to be employed. The Trump administration is likely to approve such waivers, despite little evidence that work requirements in Medicaid are effective in encouraging people to find employment, Leighton Ku, a professor of health policy and management at George Washington University, told Bloomberg BNA.

“The Trump administration has shown it’s willing to go ahead with approving waivers,” Ku said. “It’s likely they’ll approve them if states ask again.”

Several Republicans in the House want to allow states to add work requirements for childless adults as part of their Obamacare repeal bill, slated for a vote March 23. If enacted, this change would allow states to install these requirements without a waiver from the federal government.

This change could prompt several states, particularly those that expanded their Medicaid programs under the ACA, to pursue work requirements. These requirements typically target nonelderly, childless adults, who make up a small portion of all Medicaid beneficiaries.

Medicaid, the public health insurance program for the poor that covers more than 70 million Americans, is largely populated by children, people with disabilities that limit their ability to work and retired seniors, according to a January report by the Kaiser Family Foundation.

The ACA added an estimated 11 million nonelderly adults in Medicaid by allowing states to expand their public insurance programs to cover anyone whose income is less than 138 percent of the federal poverty line, roughly $17,000 per year. Many Republican lawmakers have balked at this change, saying Medicaid should be reserved only for the disabled, seniors and poor families.

“Obamacare was a vehicle for adding able-bodied adults to Medicaid,” Rep. Jodey Arrington (R-Texas) said March 20 during a House Budget Committee hearing on the Republican bill to repeal the ACA.

House Republicans want to give governors the power to require people over 18 who don’t have a disability or dependent children to work or perform community service a certain number of hours each week, similar to the requirements for people who receive federal food assistance.

Proposed Requirements

The federal government hasn’t allowed any states to put work requirements into their Medicaid program, Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities, told Bloomberg BNA. Four states—Arkansas, Arizona, Kentucky and Pennsylvania—have requested them, she said.

The four states each had different definitions for which Medicaid beneficiaries would be subject to work requirements and what those requirements would entail. They ranged from capping the number of years working-age beneficiaries could be covered by Medicaid to requiring beneficiaries to work or volunteer a certain number of hours each week in order to maintain their coverage.

All four largely targeted their expansion population for these requirements.

Kentucky, in its 2016 request for a waiver from some federal requirements of its Medicaid program, sought to require “able-bodied working age” childless adults who have been on Medicaid for a year to volunteer or work at least 20 hours per week.

Arizona in 2016 sought to limit Medicaid beneficiaries considered “able-bodied” to five years of coverage, Ku said.

Maine Gov. Paul LePage (R) has said repeatedly he wants to put work requirements in the state’s Medicaid program, but hasn’t outlined specifics. Maine hasn’t expanded its Medicaid program, making it unclear how many nonelderly childless adults are on the state’s Medicaid rolls.

Indiana’s Medicaid expansion program was granted a waiver by the Centers for Medicare & Medicaid Services that allowed the state to refer Medicaid beneficiaries to the state’s work training and job search programs. The waiver, designed in part by now-CMS Administrator Seema Verma, doesn’t allow the state to require beneficiaries to be employed.

Questionable Effectiveness

Health policy observers from both sides of the political spectrum have questioned the usefulness of Medicaid work requirements. Many see them as messages, meant to paint the ACA’s Medicaid expansion as a giveaway to people unwilling to work at the expense of the needy.

Work requirements would push adults with serious health conditions off Medicaid, rather than encourage them to work because hospitals and clinics cannot deny people care if they don’t have insurance, Robert Rector, a senior research fellow with the conservative Heritage Foundation, said in a March 17 op-ed in the Daily Signal, a Heritage news site.

Those pushed off Medicaid would rely on charity care or face mounting bills, he said.

“If enacted, work requirements in Medicaid would certainly be symbolic rather than substantial,” Rector said.

Getting Medicaid beneficiaries to work more also doesn’t mean they will obtain health insurance, Ku said. Many poor Americans work in the service or construction industries, where few low-wage workers are given insurance.

Roughly 80 percent of adults on Medicaid are either employed or part of a family with at least one working member, according to the Kaiser Family Foundation. These adults tend to work for small companies that don’t offer health insurance or work only part time, according to Kaiser.

“The connection between work and health insurance is extremely slim for many,” Ku said.

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