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« Congress Acts to Fund Key Health Priorities, But Leaves Dreamers Behind | Main | The march for women’s health is far from over! »

How would Medicaid waivers hurt women and LGBTQ people?

The dangers of proposed Medicaid work requirements
House Speaker Paul Ryan (R-WI)—rumored to be retiring at the end of the year, with possible presidential ambitions—still wants to bolster his conservative legacy by forcing a vote on a stand-alone package of “reforms” that he hopes can win the support of vulnerable red-state Democratic senators. Using Orwellian phrases like “personal responsibility” and “promoting independence,” he wants to push forward radical changes to the Medicaid statute that would allow or require states to impose work requirements, drug testing, onerous new paperwork burdens and more.
With the blessing of the Trump administration’s Center for Medicare and Medicaid Services (CMS), states are already attempting to ram through these changes under the guise of “demonstration projects.” But because the statute itself does not grant this leeway, these state waivers are subject to litigation.Former CMS official Eliot Fishman recently wrote about why:
"[W]aivers must meet a legal requirement that they try to strengthen the Medicaid program: by expanding coverage, improving care delivery, or help safety net hospitals and other providers. But CMS’s recent announcement is directly opposed to the central Medicaid goal of covering low-income people. This is the first time in the 52-year history of the program that Medicaid waivers have been approved to reduce coverage instead of to expand it."
If Republicans are successful in changing the underlying law itself, they may have achieved through the backdoor, many of the same coverage losses they’d hope to carry out through block grants and other proposed direct coverage cuts last summer. The danger is that, right now, few people understand what “work requirements” really mean. Moreover, Senators up for re-election this year from conservative states may be reluctant to vote against proposals that appear to be getting people back to work.
In reality, there are very few Medicaid beneficiaries who could be working but aren’t. As the Center on Budget and Policy Priorities notes, the overwhelming majority of adults with Medicaid already work, are too sick to work, are going to school, are taking care of family members, or are already actively looking for work and can’t find it.
Work requirements won’t change those circumstances, but the red tape associated with compliance will cause many of those people to lose coverage. As the New York Times recently reported, “a large body of social science suggests that the mere requirement of documenting work hours is likely to cause many eligible people to lose coverage, too.” As the article notes, “these [administrative hurdles] may be especially daunting for the poor, who tend to have less stable work schedules and less access to resources that can simplify compliance: reliable transportation, a bank account, internet access.”
The consequences for women and people of color would be particularly severe, as we noted in our 2016 research brief. While women and men have had roughly equivalent unemployment rates post-recession, women are far more likely to work part-time, making them vulnerable to the kinds of hourly requirements legislators have proposed. In 2014, for example, women accounted for 66% of the part-time work force and only 41% of the full-time workforce. Likewise, since the 1940s, the unemployment rate among African Americans has been consistently double that of white Americans.
Work requirements would also have serious consequences for LGBTQ people, who may disproportionately fall within the category of “able-bodied adults without dependents,” which work requirements often seek to target. It’s likely that the states where work requirements are more likely to be adopted are also the states with few or no workplace protections for LGBTQ people. In other words,  LGBTQ people could be subject to work requirements, while also facing discrimination that keeps them from being hired, or causes them to be fired.
A few weeks ago, Kentucky became the first state to gain approval for a Medicaid waiver that will impose harmful work requirements on Medicaid recipients. RWV and our Louisville-based RC, Kentucky Health Justice Network, submitted joint comments urging the state not to pursue work requirements, and highlighting the negative impact they will have on Kentucky women. Officials estimate that the waiver’s approval will lead to as many as100,000 Kentuckians losing coverage (a number that doesn’t even account for the people who will be deterred from seeking Medicaid coverage in the future). This will have serious implications for Kentucky women, particularly the 22% of Kentucky women between the ages of 15 and 49 who depend on Medicaid for health coverage.
Unfortunately, work requirements are not the only harmful provisions making appearances in state Medicaid waiversStates are seeking to impose premiums and lock-out periods, mandate drug testing, eliminate retroactive coverage, and impose lifetime limits on coverage, all of which will have devastating consequences for women. Some states, such as New Mexico, have used their waiver applications to try to limit eligibility for family planning services and supplies. Earlier this week, we submitted joint comments with our Albuquerque-based regional coordinator, New Mexico Religious Coalition for Reproductive Choice, urging CMS to reject harmful aspect of New Mexico’s proposed waiver.
We’ll be continuing to follow and comment on Medicaid waivers being put forth by other states, and highlighting their impact on women and LGBTQ people.
Congress stalled on must-do actions
Meanwhile, Congress is still nowhere close to a deal on several major issues with significant implications for health policy. Four months into fiscal year 2018, Congress still can’t agree on FY 2018 funding levels or a budget deal to prevent sequestration, the deep, automatic, across-the-board cuts set to hit everything from the military to family planning and HIV/AIDS services to road and bridge safety. Hardline conservatives are happy to let sequestration hit non-defense priorities like health care, education, and infrastructure, but are pushing for new spending for the Pentagon. Democrats have said that’s a non-starter.
Moreover, there’s little evidence that Congress is any closer to a resolution to the threat created for nearly 800,000 “Dreamers” as a result of the president’s decision to terminate the Deferred Action for Childhood Arrivals (DACA) program. There are significant concerns that, even if the Senate can pass something, Republican leadership in the House won’t bring it to a vote unless moderate Republicans face more public pressure.

If there’s a silver lining to this madness it’s that the likelihood of a third round of reconciliation seems less and less likely the deeper we get into 2018 with so many must-pass items left undone. Reconciliation is the special process that allows GOP leaders to bypass a Democratic filibuster in the Senate and pass legislation with just 50 senators and the vice president. Last January, Congressional Republicans announced a plan to use an FY 2017 reconciliation package to kill the ACA and Medicaid, and then use another reconciliation package for FY 2018 to enact deep tax cuts for themselves and their wealthy donors. Republicans had hoped to use a third reconciliation package for FY 2019 to launch another attack on health care and the social safety net.  But with their Senate majority reduced by one following the surprise special election of Democratic Senator Doug Jones (AL) and time running out on their long to-do list, it appears that reconciliation may no longer be a threat.
If that holds true, it’s great news for protecting the ACA and Medicaid, as well as Planned Parenthood and other abortion providers who were at risk of losing their ability to bill Medicaid for services in all of last year’s Trumpcare proposals. But that doesn’t mean we can breathe a sigh of relief quite yet.
RWV News!
Today, one of RWV’s three coordinating organizations – MergerWatch – joined the national consumer health advocacy organization Community Catalyst to create a Women’s Health Program.  The new program will continue to work in close partnership with the National Women’s Health Network and the Black Women’s Health Imperative to guide RWV. To learn more, see Community Catalyst’s press release.
The newest addition to the RWV website is here -- the events calendar. Check out the upcoming events RWV staff and/or our Regional Coordinators will be participating in across the country! Click here to learn more, including whether you or your organization could participate. For more information or questions, please contact RWV's Regional Field Manager, Kalena Murphy at


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