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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



The march for women’s health is far from over!

Our fight continues in Washington and across the country
Raising Women’s Voices marched for women’s health across the nation over weekend.  In New York City, for example, Raising Women’s Voices-NY graduate student intern Empress James raised our banner high in one of the largest of the weekend’s women’s marches.
Our fight continues this week in Washington, where Raising Women’s Voices staffers Sarah Christopherson, Kalena Murphy and Ann Danforth are attending the Families USA annual conference. Also on hand are some of our RWV regional coordinators, including Consumer Health First from Maryland, Maine Consumers for Affordable Health Care,New Jersey Citizen Action and EverThrive Illinois. They’ll be connecting with other health care advocates and attending panels throughout the week to discuss what’s ahead in 2018, how we can work together to protect and expand women's health and LGBTQ health, and how can make real progress toward health equity.

This morning, they cheered on U.S. Senator Cory Booker, a New Jersey Democrat, when he told the conference attendees, “We can’t say we are a country who believes in life, liberty, and the pursuit of happiness if all people do not have access to health care.”

Congress renews CHIP, but  fails to act on health centers, Dreamers
After a brief government shutdown over the weekend, Congress passed a short-term funding bill on Monday to re-open government through February 8—the fourth such stop-gap funding bill since the start of the 2018 fiscal year in October. We were relieved that after months of hostage-taking, Congress finally reauthorized the Children’s Health Insurance Program (CHIP) for six years, providing needed coverage for nine million children. States that had already taken steps to freeze their enrollment and shutter their programs now have the certainty they need to get their programs back on track.

Unfortunately, the package passed this week leaves undone a number of key priorities. These include funding for community health centers, funding for disaster relief for Puerto Rico or the U.S. Virgin Islands months after the islands were devastated by Hurricane Maria, and resolution of the future for 800,000 Dreamers, thousands of whom have already lost their legal status.
Congress delayed for several years certain taxes that were supposed to be imposed under the Affordable Care Act, such as the medical device tax, the tax on health insurance companies  and the “Cadillac tax” on high cost health plans. Those delays added more than $31 billion to the federal deficit without a “pay-for,” which means a corresponding cut in federal spending so that the result would be neutral from a budgetary standpoint.
But meanwhile, in an egregious example of a political double standard, Republicans in Congress have refused to fund community health centers without corresponding cuts to other health care programs. In the midst of a major flu epidemic that has already killed dozens of children and an ongoing opioid crisis, over a thousand community health centers around the country have been forced to postpone hiring, or even lay off staff.
The fate of the Dreamers is as uncertain as ever. Named for the DREAM Act, which would provide them with a pathway to citizenship, the Dreamers are undocumented immigrants brought to the U.S. as children, many of whom have known no other home.  In 2012, President Barack Obama created the Deferred Action for Childhood Arrivals (DACA) program by executive order, granting limited legal status and work authorization to the Dreamers. Under DACA and other Obama-era initiatives, DHS officials were directed to prioritize immigration enforcement against individuals with violent or criminal backgrounds.
In 2017, however, the Trump administration canceled DACA, rescinding legal protections for Dreamers after March 5, 2018, and directed immigration officials to arrest and deport otherwise law-abiding immigrants. Under Trump’s direction, immigration raids have been targeted at schools, churches, hospitals, workplaces, and even family courts, where undocumented victims of domestic violence have sought protection against abusive partners.
Unless Congress takes action, the end of DACA will be not only a looming humanitarian crisis, but also a health crisis. Over 90 percent of the Dreamers surveyed in a recent study are currently employed, and hundreds of thousands of them get their health insurance through their employer. So, loss of their work permits also means the loss of their health care. “At the Families USA conference this morning, Gaby Pechco of The Dream.US spelled out the consequences for Dreamers: “I’m not going to have my DACA anymore, which means I’m not going to have my job, which means I’m not going to have any health care, which means I won’t have access to the medication I need to have babies.”

In New York, Governor Andrew Cuomo took steps to protect the health of New York Dreamers who might lose their jobs.  He announced that the 42,000 New York Dreamers will still be eligible for state-funded Medicaid coverage, regardless of their immigration status. "The federal government's failure to take action to protect DACA recipients is appalling, un-American, unjust and puts hundreds of thousands of children at risk,” Cuomo said. “Here in New York we will do everything in our power to protect DACA recipients and ensure they receive health care.”
In exchange for re-opening the government this week, Senate Republican Leader Mitch McConnell (R-KY) promised Democrats and moderate Republicans that the Senate would vote on a DACA package. But the House conservatives who determine whether current Speaker Paul Ryan (R-WI) retains his Speakership have sworn that the House won’t vote on the Senate package.
While pundits obsess over the horserace question of who “won” or “lost” the shutdown, the truth is that the fight has simply been delayed for three weeks. By February 9, the GOP’s long-standing hostility to the Dreamers won’t have faded, setting up the potential for another government shutdown. Fortunately this time around, the GOP will no longer be able to use CHIP as a cudgel.
Voters in Oregon approve funding for continued Medicaid expansion 

On Tuesday, Oregon voters overwhelmingly approved a ballot measure that will protect access to health care for Oregon women and families by preserving Medicaid expansion in the state. Measure 101 will allow the state to continue taxing hospitals and certain health insurers to help pay for the state Medicaid expansion program. Through Medicaid expansion under the ACA, Oregon has achieved one of the highest uninsured rates in the country, with close to 94% of the state insured. At stake in this referendum was the health coverage of 350,000 low-income Oregonians, including women who rely on Medicaid for critical reproductive health services, said supporters of the measure.

NARAL Pro-Choice Oregon, the political action arm of our Portland-based RWV regional coordinator Oregon Foundation for Reproductive Health, worked hard alongside nurses and doctors, firefighters and teachers, AARP, local hospitals and families across the state, to ensure that Measure 101 passed. NARAL Pro-Choice Oregon made phone calls and led a door knocking campaign to urge people across the state to support the measure.

Following Tuesday’s vote, Hannah Rosenau, Program Director at NARAL Pro-Choice Oregon (second from right in photo), said “We are proud to be a part of the successful YES on Measure 101 coalition, standing with over 175 organizations representing hundreds of thousands of Oregonians to protect and support health care. We believe that everyone deserves access to affordable health care and Medicaid is essential for children, people with disabilities and working families in Oregon.”



Trump rule a #LicensetoDiscriminate

Raising Women’s Voices calls on HHS to #PutPatientsFirst

Today, the Trump administration proposed a sweeping new rule designed to ensure that health care providers – hospitals, insurance plans, doctors, nurses, technicians and even volunteers at hospitals – can refuse to provide medical care to which they have religious or moral objections.  We fear the result could be the enshrining of discrimination against women and LGBTQ people, denying them not only needed care, but also the information they need to make informed health care decisions and find alternative medical providers when they are refused care.

Nowhere in the 216-page proposed rule is there an explanation of how the Department will ensure that patients can get the medical care they need, when their health providers refuse.  In fact, the proposed rule specifies that an objecting health provider cannot be required to even provide patients with a written notice about where else they can go to obtain needed care. There is no explanation of what a hospital should be expected to do when a patient desperately needs emergency care, such as treatment of a miscarriage or ectopic pregnancy, but the facility objects on religious grounds. 

The rule was issued on the same day that a new study reported that women of color in 19 states are disproportionately affected by Catholic hospital restrictions on reproductive health care. Among the pregnant women who have been harmed by such refusals is Tamesha Means, pictured, who was turned away from the emergency department at a Catholic hospital in Michigan, after presenting with premature rupture of membranes. Only when she returned to the ER for the third time did she finally receive needed care, but she suffered an unnecessary infection as a result of the delay.

In contrast to the lack of protections for patients, the proposed HHS rule would requirehealth care institutions to prominently post government-specified notices about the rights of employees to refuse to deliver medical care they find objectionable. Institutions would face the potential loss of federal funding for non-compliance.

Existing federal laws already allow individual clinicians and health care institutions to refuse to provide such services as abortions and sterilizations, based on religious beliefs. So, is unclear why HHS needs to take these additional steps, especially when the Department itself estimates it will cost affected entities (such as health providers, insurers and state governments) $312.3 million to implement in the first year and $125.5 million annually after that.  HHS could better spend such funds enforcing, rather than undermining, section 1557 of the Affordable Care Act, which prohibits discrimination against women and LGBTQ people in the provision of health care.

The religious objections of a health care provider cannot be allowed to leave a patient without access to timely medical information and care. In health care, the patient’s rights and needs must come first!



Trump wants health providers to get #RXtoDiscriminate

New HHS Effort to Protect Religious Health Provider Refusals

While most of Washington was busy trying to prevent the federal government from running out of money, reauthorize the Children’s Health Insurance Program (CHIP) and reach agreement on saving the Dreamers, the Department of Health and Human Services (HHS) had a different priority in mind. In a press release and special event this morning, HHS announced the creation of a new Conscience and Religious Freedom Division dedicating to protecting health providers that want to deny medical care because of religious or moral objections.

In other words, Trump wants to give religiously-motivated medical providers an #RXtoDiscriminate against women and LGBTQ patients!

Acting HHS Secretary Eric Hargan claimed that “For too long, too many of these health practitioners have been bullied and discriminated against because of their religious beliefs and moral convictions.”

The truth is very different: Women have suffered denials of needed care by individual clinicians and by hospitals claiming religious or moral objections.Pharmacists have refused to fill prescriptions for birth control. Pregnant women experiencing miscarriages have been turned away by hospital emergency departments. Women giving birth have been denied post-partum tubal ligations. In some states, women of color have been disproportionately affected by Catholic hospital refusals, according to a new study being released Friday by the Public Rights/Private Conscience Project at Columbia University Law School.

LGBTQ people have also been harmed. Lesbian couples have been denied infertility services by doctors who object to same-sex couples and families. Patients needing gender transition services, such as hormones or surgery, have been turned away.

HHS should be protecting patients’ ability to obtain health care and providers’ ability to provide that health care, rather than devoting unnecessary increased resources to a new office focused only on protecting those who would deny patients care. In particular, HHS needs to do more to enforce, rather than attempt to undermine, Section 1557 of the Affordable Care Act, which has provided important new non-discrimination protections to women and transgender individuals in this country. We need HHS to #PutPatientsFirst, not give health providers a #LicensetoDiscriminate! 
Raising Women’s Voices will close monitor what the new HHS office does. We are awaiting issuance of a new rule that reportedly will expand on existing provider refusal rights, and will be submitting comments on how that would affect women and LGBTQ people.

The GOP’s Cynical Bargaining CHIP

Meanwhile, Republicans in Congress have put forward a bill this week that funds the government for an additional four weeks—the fourth such stop-gap funding bill since the start of the 2018 fiscal year in October—and reauthorizes the Children’s Health Insurance Program (CHIP) for six years.
Unfortunately, the package is as notable for what it doesn’t do as what it does. The bill fails to fund community health centers or other key health priorities which expired at the end of September, fails to fund disaster relief for Puerto Rico or the US Virgin Islands months after the islands were devastated by Hurricane Maria, and leaves 800,000 Dreamers without legal protections. Republicans crafted their package without Democratic input in the hopes that Democrats would balk at voting against CHIP, a program they’ve long championed.

As of this writing, it’s unclear whether Republicans have the votes to pass their package and avoid a government shutdown on Saturday. If the House passes its package on Thursday, the path through the Senate is even trickier, where two Republicans have already announced their opposition to the bill on the grounds that it doesn’t provide enough funding for the military.

As we noted last week, the Centers for Medicare & Medicaid Services (CMS) has warned that some states will run out of CHIP funding by January 19 (tomorrow!). But if the package fails, Republicans can still bring up CHIP as stand-alone legislation at any time—as they could have done at any point thus far. Regardless of what happens this week, we will be pushing Congress to fund CHIP for at least six years (if not longer) and fulfill its responsibilities to the Dreamers and the U.S. citizens of Puerto Rico and the U.S. Virgin Islands, thousands of whom are still without power.



Top of Our "To Do" List: Reauthorize CHIP!

First On Our “Must Do” List for Congress: Reauthorize CHIP!
For the first time since they left Washington, D.C., for the holidays, both chambers of Congress are back this week with a full slate of must-pass legislation left over from last year.
Top of the “must-do” list for us is a long-term reauthorization of the Children’s Health Insurance Program (CHIP), which expired in September. CHIP funds health insurance for nine million kids, including two million children with serious chronic conditions. Without guaranteed long-term federal support, states are spending down reserves and moving to cut off new enrollments as a first step to shutting down their CHIP programs altogether.
In December, Republicans chose to prioritize passing deficit-busting tax cuts for billionaires over reauthorizing health care for kids. Instead, Congress passed a short-term funding patch that was intended to keep the program afloat through the end of March. But, the Centers for Medicare & Medicaid Services (CMS) has warned that some states will run out of money by January 19.
While there is strong bipartisan support for CHIP, the parties have split over how to pay for the program, with Republicans insisting on deep cuts to other critical health programs to offset CHIP’s costs. In a plot twist this week, the prospects of a deal became stronger when the price tag for a 5-year reauthorization of CHIP fell from $8 billion to under $1 billion. 
Why the change? By repealing the Affordable Care Act’s individual mandate, the Republican-passed tax bill is projected to drive up ACA premiums in 2019, because fewer healthy people will buy coverage. The result will be that ACA coverage will be more expensive for the government to subsidize than it would otherwise have been. If CHIP were to lapse, budget scorekeepers predict that some of the children currently insured through CHIP would move to the now-more-expensive ACA plans. If CHIP were to be reauthorized, however, the government’s “new” spending on CHIP would only be $800 million over current law.
It’s an only-in-Washington solution: Republicans made their CHIP spending problem magically disappear by raising the government’s other costs. In fact, a 10-year reauthorization of CHIP--  instead of 5-year deal -- would now save the government $6 billion, leading Democrats to call for a longer-term or even permanent renewal. With funding for the overall government also set to expire on January 19, there is a chance that CHIP could be added to another short-term funding bill—if Congress feels pressure to act.
At the same time, Congress is struggling to come together on a host of other must-pass deals with big implications for women, people of color, immigrants and the LGBTQ community.
Following a televised negotiation at the White House in which Donald Trump both agreed to and rejected passing a clean DACA deal to help Dreamers brought to the U.S. as children, it’s unclear what will happen next. Anti-immigrant Republicans in Congress and the administration are pushing a wasteful $18 billion border wall as their price for restoring basic employment and health care rights to the Dreamers. A  court decision this week temporarily reinstating DACA nationwide, while positive, could take the pressure off of Republican moderates to find a legislative fix.
Meanwhile, the two parties still haven’t reached a deal to waive “sequestration” (the automatic spending cuts mandated by the 2011 Budget Control Act) for Fiscal Years 2018 and 2019, even though we’re four months into FY18. If these cuts were to take effect, both defense and non-defense funding would be slashed, including a host of health-related programs ranging family planning through Title X to HIV/AIDS medical care through the Ryan White program.
The other big news this week was an announcement by the Trump administration that states will now be allowed to include work requirements in their Medicaid expansion proposals. The Obama administration had long resisted approving work requirements, arguing that they violate long-standing Medicaid law. Under the law, state proposals must “assist in promoting the objectives of [Medicaid]” to expand medical care to the needy. At best, work requirements do nothing to expand access to care and at worst, lead to denials of care, with major consequences for women and people of color.
In our 2016 report on state Medicaid proposals, we noted that 60 percent of the then-nearly 3 million adults in the Medicaid coverage gap were already working. Among those not working, the vast majority are students, care-takers, those too ill to work and those already actively looking for work.
From a public health perspective, it makes little sense to deny coverage that helps prevent the spread of disease, allows the mentally ill to access care, and ensures that family members are able to care for individuals who might otherwise require more costly services like nursing homes.
The consequences for women and people of color would be particularly severe.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 percent of the part-time work force and only 41 percent of the full-time workforce. Likewise, since the 1940s, the unemployment rate among African Americans has been consistently double that of white Americans.


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