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Thursday
Apr252019

Medicaid work requirements not really about work

Medicaid work requirements not really about work

This week, our last article for Medicaid Awareness Month highlights the ways that conservatives are using bureaucratic red tape to dismantle Medicaid from within by making coverage impossible to retain.

In 2017, congressional Republicans tried to gut long-standing coverage guarantees in traditional Medicaid under the pretense of repealing the Affordable Care Act. When thatfailed, the Trump administration quickly switched to encouraging states to load up their Medicaid programs with so much red tape that eligible people would lose coverage.

Dressed up in rhetoric like “improv[ing] Medicaid enrollee health and well-being through incentivizing work and community engagement,” the true intent of these efforts is to make compliance with the rules so cumbersome that few can do it.

Making Medicaid coverage conditional on meeting work requirements is a particularly compelling example because 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 trying to prove compliance will cause many of those people to lose coverage. As the New York Times reported last year, “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.” 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.”

That means that hundreds of thousands of eligible low-income women—including those who are already working, who are serving as an unpaid care-giver, who are disabled, or who should qualify for an exemption—will lose their coverage anyway simply because they can’t keep jumping through all of the right hoops.

But for the Trump administration, that’s a feature, not a bug. In Arkansas, for example, the Center for Medicare and Medicaid Services (CMS)—led by Vice President Mike Pence’s close ally Seema Verma—approved a waiver designed to make it as difficult for working Arkansans to report their work hours as possible. In Kentucky, state health officials boastedthat their waiver would save the state money because 95,000 eligible Kentuckians would lose coverage.

While the Obama-led CMS rejected work requirements, Trump’s CMS has approved them under the guise of “demonstration projects” in 9 states: Arkansas, Kentucky, Indiana, New Hampshire, Arizona, Michigan, Ohio, Utah, and Wisconsin. An additional 6 states—Alabama, Mississippi, Oklahoma, South Dakota, Tennessee, and Virginia—have work requirement proposals pending with CMS. But because the law doesn’t give CMS this authority, these state waivers are subject to litigation. Last year, we quoted former CMS official Eliot Fishman explaining 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."

Thus far, the courts have agreed. After more than 18,000 people lost coverage in Arkansas, the only state to have had a work requirement go into effect thus far, federal district court Judge James E. Boasberg ruled that CMS “had not adequately considered whether the program ‘would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid’” and concluded that the agency’s “approval cannot stand.” The same judge delayed implementation of Kentucky’s work requirement before it could begin, pending the outcome of litigation. New Hampshire is currently scheduled to start taking away coverage from people who fail to meet its work requirements on August 1, though a lawsuit filed against that waiver is also headed to Judge Boasberg’s court. The cases may ultimately end up before the Supreme Court.


Even in states that haven’t expanded Medicaid or initiated work requirements yet, thousands of low-income women, children, and families have lost their coverage because they couldn’t keep up with the bureaucratic paperwork demands. In Tennessee, 1 out of 8 children lost coverage in a two-year period because of paperwork. In Texas, repeated, unnecessary income checks have “led to thousands of kids being abruptly kicked off the program — and data shows that many of those removals were in error,” according to the Texas Tribune.

Having successfully fought to save Medicaid from congressional attacks and proved the popularity of Medicaid expansion through ballot initiatives, advocates must not lose sight of the ways that conservatives are seeking to hollow out Medicaid from the inside out.

Just as the onslaught of anti-abortion state laws have made the Constitutional right to an abortion a right in name only for millions of women, so too do conservatives hope to make Medicaid coverage exist in name only, turning it into a health care program for the poor so riddled with bureaucratic red tape that even wealthy households would struggle to cut through.