The Hippo


Apr 5, 2020








Working for Medicaid
How a new work requirement might affect recipients

By Ryan Lessard

 If a work requirement proposal is approved by the federal government, thousands of Granite Staters could find it harder to keep their Medicaid health insurance.

An amendment to the state budget trailer bill, HB 517, included a work requirement attached to expanded Medicaid. Now that the budget has been signed into law, the state must receive a waiver from the federal government to allow such a requirement to be enforced. 
Researchers say if such a plan is approved and implemented, it could impact about 30 percent of Medicaid recipients and it would disproportionately affect vulnerable communities.
“We found, like in much of the existing research, about three in 10 Medicaid recipients might be affected by a work requirement and we found that that share is actually similar across rural and urban places,” said Jessica Carson, a researcher at the Carsey School of Public Policy at the University of New Hampshire.
The research looks at Medicaid recipients nationwide.
Currently, there are about 52,300 adults enrolled in the expanded Medicaid program, according to Phil Sletten, policy analyst at the New Hampshire Fiscal Policy Institute. If 30 percent of those are affected, that would mean more than 15,600 people could be forced to work more or lose their coverage.
“We’re talking about folks who work some of the year. They either worked part of the year, not 52 weeks straight, or they worked fewer than 20 hours [per week] year-round,” Carson said.
The rules proposed for New Hampshire would require recipients to work a minimum of 20 hours a week each week in the first year, 25 hours in the second year and 30 hours by the third.
Still, Sletten said there are some exceptions to the rule.
“If sufficient private sector employment in not available, then the requirement can be fulfilled with work experience. The example that’s provided in statute is refurbishing of public assisted housing,” Sletten said.
The requirement can also be met with job search assistance, job readiness assistance, vocational training or job skill training. The recipient would have to meet the same hourly requirement with these programs or a combination of these programs and hours from work.
Carson said the work requirements proposed around the country often disproportionately affect people with less education, women and racial and ethnic minorities. It can also prove difficult for people who are caring for children, parents, spouses or other family members who have disabilities. 
In New Hampshire, Sletten said, there would be exemptions for caretakers if a licensed health care professional considers the care to be required and there are no other caretakers available.
Medicaid is offered to caregivers of a child under age 6.
Many expanded Medicaid recipients in New Hampshire are using the coverage to receive substance use disorder treatment, which many treatment providers and advocates say has been a game-changer.
While it’s unclear whether substance use disorder would qualify, exemptions can be granted to individuals on a case-by-case basis if a certified health professional affirms they are temporarily unable to fulfill the work requirements.
There’s also an exemption for folks enrolled in a state-certified drug court program.
The work requirements only apply to “able-bodied adults” as defined by the federal government. 
Possible side effects
Carson said the new rules, if approved, would mean an additional administrative cost for the state in order to enforce a work requirement. 
“Somebody has to check that. Somebody has to enforce that,” Carson said.
Caregivers with older children may need to start paying for child care.
“If someone is receiving health insurance through [expanded Medicaid] and their child changes in age from 5 to 6 and then they may not be eligible for the exemptions … that may impose some costs on them,” Sletten said.
And, more generally, creating an extra task for poorer people to perform in order to keep their insurance may be more complicated than it seems on the face of it.
“Given that low-income workers regularly face job instability, tracking and approving periods of inconsistent employment could be cumbersome,” Carson said.
If someone fails to get extra work or fill the gap with other programs like job training, they’ll lose their coverage. That, Carson said, could result in the opposite of what the expanded Medicaid program set out to do and result in less employment rather than more.
“People who are in good health are more likely to work and people who work are in better health,” Carson said.
The work requirement was something the state GOP wanted since the legislature first created its own expanded Medicaid program under the Affordable Care Act, called the New Hampshire Health Protection Program.
It was included in the most recent reauthorization of the program, but the Centers for Medicare and Medicaid Services denied that waiver request. 
“[CMS] said that these [requirements] would not improve health outcomes or coverage for low-income individuals or increase access to providers. So it wouldn’t further the objective of the Medicaid program,” Sletten said.
But that was during the Obama administration. Now, the Trump administration is widely believed to be friendlier to the idea of a work requirement.
“The legislators who forwarded this amendment and advocated for it to be in the budget, some of those legislators expressed publicly that they believed that the new administration may be more open to having work requirements in the Medicaid program than the prior administration,” Sletten said.
In the previous reauthorization bill, the continuation of the program did not hinge on the approval of the work requirements. 
But it does now. If CMS denies the request again by April 30, 2018, letters will be sent immediately to expanded Medicaid recipients stating the program will end by Dec. 31, 2018. 
However, that is the existing sunset date for the program already. The legislature will likely revisit the program and have an opportunity to reauthorize it to extend past that date regardless of the ruling on work requirements. 

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