Medicaid, the federal entitlement program that serves one in five low-income Americans, could see more restrictions despite the fact that the Medicaid expansion provision under the Affordable Care Act was intended to make it easier for single adults with no children to gain access to health coverage if they could not afford private insurance and were not covered through their jobs. Under Seema Verma, the Trump administration's director of the Center for Medicare & Medicaid Services, the federal government has been encouraging states to submit proposals to modify Medicaid eligibility on the state level (often called Section 1115 waivers). Waivers allowing work requirements as a precondition for coverage, a change that Verma has long championed, are a major shift in how the program has functioned since its inception in 1965.
The ADAP Advocacy Association hosted its annual conference in late September, and the conference covered many subject areas along this year's official theme, "Mapping a New Course to Protect the Public Health Safety Net." One panel was dedicated to trends in Section 1115 waivers, including the work or “community engagement” requirements that have been designated markers of eligibility in many states. Such requirements include working (and documenting) employment or other community engagement activities -- approximately 20 hours per week.
Four states have had waivers approved for Medicaid work requirements, while eleven states have applied for waivers and are awaiting approval.There are other states that are discussing 1115 waivers, but have not submitted any proposals to CMS. Despite the stereotype of Medicaid enrollees being unemployed and a drain on the system, in fact, 80% of households that receive Medicaid have someone working, and 60% of people who receive Medicaid are working full or part time. Their wages are still low enough to remain Medicaid eligible, however. Each state has its own threshold for Medicaid eligibility, but states have to abide by the standard set of at least 100% of the federal poverty level if they haven't expanded Medicaid.
Arkansas was the first state to implement a work requirement for Medicaid eligibility in 2018. New Hampshire and Indiana will have work requirements go into effect in 2019. In addition to work requirements, some states have, or are planning to implement reporting requirements that make maintaining coverage difficult. Since November 2015, over 91,000 people in Indiana have lost their Medicaid coverage due to not submitting specific paperwork on time, according to a report from National Public Radio (The current CMS Director was the architect of the Indiana plan, and it is though she was chosen to work in the Trump Administration for this reason). This paperwork also requires an enrollee to provide proof of residence, income, and family size. Currently, enrollees are allowed to reapply at any time if they were disenrolled due to noncompletion of redetermination paperwork. But under Indiana’s new 1115 waiver, failure to submit the redetermination paperwork can result in a loss of coverage for three months. Other states have followed suit and are waiting approval for their Medicaid 1115 waiver applications.
Though a Medicaid enrollee might be able to find work, full-time employment could still elude them for several factors. For example, this can be the case if someone lives in an area without consistent work or lacks competency with computers or heavy equipment to fulfill job roles.
"It's definitely going to have a huge impact upon rural areas," said Eric T. Paulk, HIV field organizer with Georgia Equality.
But it's not just a burden on enrollees. The additional requirements to monitor employment, residence, income, and family size mean that a state must allocate additional resources to the administration of these tasks.
"This makes me think of the infrastructure states have to put in place to launch something like this effectively," said Maureen Hensley-Quinn, senior program director at the National Academy for State Health Policy. "I don't know that state legislatures are considering the resources they should be giving their state programs. For instance, giving a rural hospital a dedicated staff person from the Medicaid department to help educate but [also] to be there to help people report on their work. They can have broadband internet connection at places in the community that are directly connected to Medicaid. All of these things take funds, and we go back to our original discussion about states struggling with their budgets."
As previously reported by TheBody, some protections are available for people living with HIV. Some states, including Kentucky and Indiana, include HIV in the "medical frailty" classification that prohibits people from being kicked off Medicaid and from being required to work for benefits. In addition, the work requirement exemption extends to pregnant women; persons with mental health and substance issues, including opioid addiction; primary caregivers of dependents; full-time students; and some other groups.
Related: 5 Things to Know About Medicaid Work Requirements
This still does not inspire calm among some public health advocates. The work requirement follows a tactic that many states -- predominantly those that are Republican-controlled and have not pursued Medicaid expansion -- have employed since the enactment of the Affordable Care Act. Work requirements have already been attached to receipt of Temporary Assistance for Needy Families and Supplemental Nutrition Assistance Program, better known as TANF and SNAP, respectively. These added barriers limit health care access.
"Health care is a basic human right, so peoples' instincts should be doing everything they can to making sure that people have access to health care, so you don't get a pat on your head for creating a process that maybe helps a few other people," said Paulk. "I think we have to hold folks accountable. I think we have to organize better around the issue, make sure folks on the ground are equipped with the tools they need, and really make sure [that] if there's going to be a 1115 waiver, that folks are covered. Folks are going to put in some sort of gap where maybe I will have it, maybe I won't. I think we have to put more pressure on our elected officials to do what's right for the constituents."
Industry players such as Merck, which was represented on the panel by its executive director of U.S. policy, James Carey, have not weighed in on the work requirements' debate. However, Carey said that the company has leveraged its resources regarding the pharmacy considerations.
"We are advocating and, where appropriate," said Carey, "we're partnering with the community, as well. The voices of the disenfranchised populations who are most impacted by some of these things are the ones not being heard."
One mechanism to voice concerns is through public comments. Public comments were used to great effect in Kentucky's decision to block plans to expand work requirements, though it is "an imperfect system that does make a difference," said Hensley-Quinn. "When we work with state officials, they really do value hearing from individuals and advocacy organizations. And I feel confident saying that across the board regardless of the state's politics."
On Oct. 8, just a few weeks after this panel, Kaiser Family Foundation released an interim report on Arkansas, the first state under the Trump Administration to successfully implement new requirements, on June 1, 2018. According to state reporting, "more than 4,300 enrollees [had] lost Medicaid coverage as a result of the new work and reporting requirements, and another 5,000 were at risk of losing coverage with another month of non-compliance."
[Editor's note 10/31: This article has been updated to reflect updated information obtained after publishing.]