No evidence that Medicaid work requirements put people to work

Feb. 23-- Feb. 23--While the sponsor of a Medicaid work requirements bill says the intent of the legislation is to put people to work, there is no evidence that such laws do.

Some data, meanwhile, suggest that similar laws take away low-income people's health insurance.

In Arkansas, more than 18,000 people have been removed from the program since work requirements began in June. Health policy experts believe some of those people were likely working, but didn't provide proof of their employment because, among other reasons, they lacked Internet access or didn't understand the new requirements.

Similar bills have been the subject of lawsuits in two states. In Kentucky, a judge sided with the plaintiffs on the basis that putting people back to work isn't the purpose, as stated in federal law, of the Medicaid program.

The purpose of the program, the court said, is to provide low-income people, many of whom already work, with funding for health care.

----Last week, West Virginia House of Delegates Finance Chairman Eric Householder, R-Berkeley, introduced a bill in his committee that would require people who receive Medicaid in West Virginia to work, volunteer or participate in workforce training 20 hours a week.

"The goal is to allow people to get back to work so they feel good about themselves and to lower the cost to the state," Householder said in an interview.

Medicaid is a program that provides health insurance for people who make up to 138 percent of the federal poverty level, which was about $35,000 for a family of four and $16,000 for a family of one in 2018.

Prior to the enactment of the Affordable Care Act in 2010, Medicaid primarily served older people, low-income people with children and people with disabilities. The Affordable Care Act included Medicaid expansion, which made more people eligible if they met income requirements.

About 160,000 West Virginians are currently on Medicaid through Medicaid expansion. That's of about 670,000 West Virginians who were enrolled in Medicaid during 2018, more than one-third of the state, according to DHHR.

Many low-income people in West Virginia know it as their "medical card."

Householder's bill was introduced and passed out of the Finance Committee on Thursday. The committee didn't recommend it be sent to any other committees, such as Judiciary, Industry and Labor, or Health. Instead, it was sent straight to the floor where the full House will vote on it this week.

Householder said time in this session was running short to run the bill through other committees. Bills introduced in the House had to be out of committee by Saturday to pass this session.

As for why it hadn't been sent to Health, specifically, Householder said that the state Department of Health and Human Resources would be involved.

"They're our state experts, right?" he said. "But no, this bill does not deny health care to anyone.

"Could they not volunteer somewhere?" he said. "I mean, that's really what this bill's about. It's putting people back to work and getting them off of state assistance and having them focus on being productive citizens of the state."

Speaker Roger Hanshaw, R- Clay, could have sent the bill to another committee. He said he wasn't familiar with the bill. He said he generally follows the recommendation of an originating committee.

When asked whether he had any evidence the bill would help put people back to work in West Virginia, Householder, said, "Keep in mind, this is a relatively new program from CMS," a reference to the federal Centers for Medicare and Medicaid Services.

----The Trump administration encouraged states to implement Medicaid work requirements on their Medicaid expansion populations through waivers. Under Section 1115 of the Social Security Act, the secretary of the HHS can waive certain Medicaid rules to allow states to enact "experimental, pilot, or demonstration" projects. The secretary can approve only those projects that "in (his) judgment . . . (are) likely to assist in promoting the (Act's) objectives," according to federal law.

Kentucky and Arkansas, the first states approved, have been the subject of lawsuits.

In January of 2018, 15 Medicaid enrollees in Kentucky filed suit over the work requirements, arguing that the work requirement provision didn't assist in achieving Medicaid's objective of providing medical assistance.

In siding with the plaintiffs in June, United States District Judge James Boasberg noted the United States Supreme Court has held that the purpose of Medicaid is to fund medical services for the needy.

Then-HHS Secretary Tom Price argued that work would improve health and well-being, and suggested that he was prioritizing coverage for the traditional Medicaid population -- those served before the Affordable Care Act expanded Medicaid.

The judge decided that Price hadn't considered whether work requirements fulfilled Medicaid's "primary purpose," to reimburse "certain costs of medical treatment for needy persons."

He also wrote that Congress, when expanding the Affordable Care Act, "transformed" Medicaid "into a program to meet the health care needs of the entire non-elderly population with income below 133 percent of the poverty level."

The judge wrote that while HHS "spoke generally" of "creating incentives for individuals to obtain and maintain coverage through private, employer-sponsored insurance," it cited no research or evidence that enacting work requirements would do so.

Boasberg found that Price "never adequately considered whether (work requirements) would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid."

----While 15 states have applied to begin requiring Medicaid recipients to work, just two states, Arkansas and Indiana, have enacted those requirements. Arkansas is the only state that has started removing people from the program.

More than 18,000 have since lost coverage, according to a report from the Arkansas Department of Human Services.

But Arkansas hasn't said what's happened to all those people -- including whether they are now working or on an employer-based health care program.

If they are working, it's unknown whether their jobs provide health insurance or whether they would have gone back to work anyway, since Medicaid is often used while people are between jobs. So there is no proof the work requirements were effective as an incentive.

"We heard a lot about transportation as a challenge in Arkansas particularly in the rural areas," said MaryBeth Musumeci, associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation which conducted focus groups in Arkansas. "So we don't know if they're concentrated in particular geographic areas. There's just a lot that the data doesn't show. We basically just know the number each month that have lost coverage.

"What I can tell you from the work that we've done in Arkansas is that we know a substantial number of people have lost coverage already. We do not know who has started working or started engaging in another activity because of the work requirement. We do know that this population of Medicaid adults, long-standing, has been working, and our focus group enrollees confirmed for us that if they can work, they want to work and they need to work to pay the bills.

"They did not feel that having the work requirement was motivating them to work because they were already very motivated to work because they needed to work to pay the rent and keep the lights on, put food on the table, etc."

According to Musumeci, the vast majority of Medicaid recipients in Arkansas are exempt from the work requirement, such as people with children, those considered "medically frail," or pregnant women.

And most of the people who are susceptible to the requirement -- working age, non-disabled adults -- are already working, she said.

But in addition to requiring work or volunteer work, Arkansas also added another requirement -- that Medicaid recipients report their work hours monthly online.

"We have a body of research that shows that putting these additional restrictions in place can result in eligible people losing coverage," Musumeci said.

Kaiser predicts that work requirements in West Virginia will kick people off Medicaid who are working, since the vast majority of people subject to the requirements do work, but the laws require them to report that work monthly.

Musumeci said Kaiser conducted focus groups with Arkansas Medicaid recipients last fall. She said the state had done extensive outreach about the new requirement, but people still didn't know about it.

Kaiser conducted focus groups with 31 Arkansas Medicaid recipients in November 2018, as well as with safety net health care and food service providers. They found that many had trouble understanding the notices sent about the new requirements. They also found that many, particularly the homeless, lacked access to the Internet and even those who did had a difficult time setting up an online account to report their work hours.

Some needed Medicaid to manage their health conditions and be able to work, while others couldn't work due to mental health or physical health conditions but hadn't been determined to be "medically frail" enough for an exemption by the state, according to Kaiser.

"Many enrollees are already working, but may face unstable or unpredictable work hours," Musumeci and others at Kaiser wrote, in a summary of the focus groups. "Volunteering was not an option for people who needed to pay the bills. More rural areas have few job opportunities."

Email: ebeck@register-herald.com and on Twitter @3littleredbones.

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