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Work Requirements Run Counter to Purpose of Medicaid.

January 16, 2019
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Man sitting in pulled-over truck with head in handsThe purpose of Medicaid is to help low-income people access health care, making work requirements difficult to justify, according to a new commentary authored by a School of Public Heath researcher.

Writing in Public Health Reports, Nicole Huberfeld, professor of health law, policy & management and of law at the School of Law, said, “Desire to be tough on the poor has not demonstrably improved the health of the poor, and low-quality work may decrease health, yet ideas such as work requirements repeatedly arise.”

In early 2018, after efforts to “repeal and replace” the Affordable Care Act (ACA) failed in Congress, the US Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services issued a new policy encouraging state proposals to “improve Medicaid enrollee health and well-being through incentivizing work and community engagement.” Work requirements are now approved for seven states, and nine more states have pending applications to the HHS for similar waivers.

So far, work requirements appear to be a barrier to better health, Huberfeld wrote, pointing to research finding that people who are disenrolled from Medicaid become even less likely to find and keep work.

Work requirements are also taking Medicaid coverage away from people who are working, she explained, because many people do not have the time, resources, or understanding of the requirement to provide proof. Arkansas’s work requirement went into effect in June of 2018, and, by September, 27 percent of all Medicaid beneficiaries subject to work requirements in Arkansas still had not submitted their paperwork. By the end of 2018, the state had disenrolled 18,164 people from Medicaid.

But Huberfeld pointed to the June 2018 ruling in Stewart v. Azar, where a federal district court blocked the first attempt to implement a Medicaid work requirement, in Kentucky, because HHS could not justify a proposal that would harm the health of low-income Kentuckians.

The court found that the HHS Secretary, Alex Azar, had granted the waiver without addressing the fact that a work requirement would disenroll an estimated 95,000 Kentuckians, and had not evaluated what proportion of Medicaid beneficiaries would be able to transition to private insurance coverage through work.

In ruling against HHS, Huberfeld wrote, the court asserted that the purpose of Medicaid is to help people access health care, including the people who became newly eligible for Medicaid under the ACA. Therefore, according to Stewart v. Azar, HHS could not grant a waiver for a plan that would harm low-income people more than it would help. “If that analysis holds, waiver provisions that add barriers to care and negatively affect Medicaid-eligible populations’ health may be hard for HHS to justify under the Administrative Procedure Act,” Huberfeld said.

However, three more states had already received work requirement waivers by the time the ruling came down. A few months later, HHS re-approved Kentucky’s work requirement.

“Stay tuned as this story unfolds,” Huberfeld wrote.

—Michelle Samuels

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  • ACA
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  • medicaid
  • obamacare
  • politics and health
  • poverty
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