The GOP’s war on the poor: Medicaid work requirements

Now that Tea-Publicans have accomplished their one goal of passing their “tax cuts for corporations and plutocrats” bill, this year their attention will turn to punishing the poor for being poor, those damn “takers”!

The GOP’s alleged boy genius and Ayn Rand fanboy, Paul Ryan, “the zombie-eyed granny starver from the state of Wisconsin,” wants to fulfill his life-long dream of dismantling Social Security, Medicare and Medicaid, the so-called “entitlement” programs, more accurately the “social contract” programs for which people paid taxes into during their working years on the premise that it will be there for them in their retirement years.

But with the Senate down to a bare 51-49 GOP majority, the Septuagenarian Ninja Turtle, Mitch McConnell, says Entitlement reform is not on 2018 Senate agenda despite what House Speaker Paul Ryan and senior Trump administration officials say. It’s Ryan vs. McConnell on entitlement reform. House Speaker Paul Ryan’s dream of dismantling the nation’s entitlement programs in 2018 has run into a harsh reality: His own party isn’t on board.

Nevertheless, Tea-Publicans are going to chip away at the social contract programs this year. In a break from longstanding legal precedent, last week the Trump Administration Says States May Impose Work Requirements for Medicaid:

The Trump administration said on Thursday that it would allow states to impose work requirements in Medicaid, a major policy shift that moves toward fulfilling a conservative vision for one of the nation’s largest social insurance programs for low-income people.

Federal officials said they would support state efforts to require able-bodied adults to work or participate in other “community engagement activities” as a condition of eligibility for Medicaid.

Under the new policy, Trump administration officials would allow work requirements in Medicaid somewhat similar to those already imposed in other programs like food stamps, now known as the Supplemental Nutrition Assistance Program, and the welfare program known as Temporary Assistance for Needy Families.

In a speech to state Medicaid officials in November, Seema Verma, the administrator of the federal Centers for Medicare and Medicaid Services, indicated that the Trump administration would be receptive to work requirements and other conservative policy ideas to reshape Medicaid. And she criticized the Obama administration, saying it had focused on increasing Medicaid enrollment rather than helping people move out of poverty and into jobs.

“Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Ms. Verma said. “Those days are over.”

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Ms. Verma said the Trump administration was responding to requests from Medicaid officials in 10 states that wanted to run demonstration projects testing requirements for work or other types of community engagement like training, education, job search, volunteer activities and caregiving.

The Medicaid proposals came from Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Several other states are considering work requirements.

Note that the states requesting waivers are red states. Trump just made another big move that could hit his voters hard:

Harold Pollack, a health-policy expert at the University of Chicago, concludes that “Medicaid work requirements may hit Trump country hardest.”

“They could hit underemployed early-retirees who now find themselves reliant on Medicaid,” Pollack told me today. “They could hit surprising numbers of people with disabilities — including addiction to opioids — who are covered under the ACA Medicaid expansion but can’t fill the requirements. They could hit hospitals in low-income rural areas that provide services to people who have lost Medicaid and can’t pay.”

Federal law gives the secretary of health and human services broad authority to grant waivers for state demonstration projects that “promote the objectives’’ of the Medicaid program. In the past, federal officials said that work was not among those objectives.

Advocates for Medicaid beneficiaries said the new policy was likely to be challenged in court if people were denied coverage for failure to meet a state’s work requirement.

Last week, Kentucky became the first state allowed to impose Medicaid work requirement:

A day after the Trump administration announced that it would allow states to compel poor people on Medicaid to work or get ready for jobs, federal health officials on Friday granted Kentucky permission to impose those requirements.

Becoming the first-in-the-nation state to move forward with the profound change to the safety-net health insurance program is a victory (sic) for Kentucky’s Republican governor, Matt Bevin, who during his 2015 campaign for office vowed to reverse the strong embrace of the Affordable Care Act by his Democratic predecessor.

Bevin first pledged to undo the state’s expansion of Medicaid, which had helped to shrink the ranks of uninsured Kentuckians more than in almost any other state. He then pivoted to the idea of keeping the additional people in the program — with strings attached that the federal government had never permitted in Medicaid’s half-century history.

The federal Centers for Medicare and Medicaid Services announced early Friday afternoon that it had approved a “waiver” — that is, the state’s application to experiment with changes to Medicaid’s usual rules.

A recent Kaiser Family Foundation analysis found that of the nearly 25 million non-elderly Medicaid recipients, a majority are already working, meaning they qualify for Medicaid (and thus can’t afford insurance) even though they are employed, which allows them to work these jobs and still get coverage. Meanwhile, of those who are not employed, most report serious health and other impediments to working, meaning the obstacle isn’t dependency or a lack of motivation. (h/t Greg Sargent)

Margot Sanger-Katz at the New York Times analyzises, Can Requiring People to Work Make Them Healthier?

The idea behind the change is that requiring work will help move more Medicaid beneficiaries into the work force and out of poverty. And, legally, it rests on the contention that the requirements themselves will make those people healthier, since improving health is the stated purpose of the Medicaid statute.

There is not strong evidence for that contention.

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[I]t is not at all clear how much work or income alone improve health. In fact, there’s quite a lot of evidence that causality can move in the opposite direction, since health problems can make it difficult to work or go to school. It might be, as the guidance document suggests, that people who don’t work become depressed. Or it could be that some people who are depressed have a harder time getting or keeping a job. Treating their depression might ease their symptoms and improve their employment prospects. “Having the medical coverage helps people to get a job,” said LaDonna Pavetti, a vice president at the liberal Center on Budget and Policy Priorities, who has studied work requirements extensively.

Some research does suggest that a boost to income can improve people’s health. Yet a study that examined the earned-income tax credit, a program established specifically to raise the incomes of low-wage workers, wasn’t able to find any clear health benefit.

Studies of the Medicaid population suggest that most of them work already or would qualify for exceptions. The guidance says that states will need to carve out exceptions for people who are medically frail and for people with opioid addictions, so they won’t lose their benefits. But anyone who fails to complete or document their required work and loses benefits won’t get the health benefits of Medicaid coverage or any of the described health benefits that the administration says come from work. States that have asked for work requirements — 10 have submitted applications already — have estimated reductions in Medicaid enrollment, and not all because of people finding other kinds of health coverage.

More crucially, a work requirement does not guarantee that Medicaid beneficiaries will have an increased income or even find a job. Some people may be nudged by a work requirement into work they wouldn’t have done otherwise. But others may simply be kicked out of the health insurance program because they aren’t able to meet the requirement. States will be allowed to cut off Medicaid benefits to people who can’t demonstrate that they’ve completed the required number of work or activity hours or who don’t qualify for an exception related to a health problem or having a young child. Others might meet the work requirement rule and keep their Medicaid, but still remain poor, because they are able to get only a volunteer or part-time job that keeps their income low.

Work requirements have been used in other social welfare programs, and they have been studied extensively in cash assistance programs, both as pilot programs in the old welfare system and as a standard feature of the Temporary Assistance for Needy Families program initiated by welfare reform in the 1990s.  . . . The general conclusion is that the work requirement increased the number of welfare beneficiaries who worked in the short term but had little impact on their long-term employment prospects or their long-term earnings.  . . . [T]hey do not appear to have meaningfully improved the long-term financial circumstances of eligible people, who were predominantly parents of young children with low levels of education.

“The work requirement itself doesn’t necessarily lead to employment, and especially not into work that will lead them out of poverty,” said Heather Hahn, a senior fellow at the Urban Institute, who was recently a co-author of a summary of the evidence about work requirements.

Robert Rector, a senior research fellow at the Heritage Foundation, who helped write the welfare work requirements and who is a strong advocate for them in many more social welfare programs, said he does not think they are a good match for a health insurance program. Mr. Rector said he’s not surprised that work requirements failed to push people into middle-class jobs. “It is an irrational expectation, and it’s not an expectation I have,” he said.

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There are likely to be legal challenges to any approved requirements, and the court cases are likely to hinge on the question of whether a work requirement can promote health. Eliot Fishman, who ran Medicaid’s state demonstrations program until May, and is now a senior director at the consumer advocacy group Families USA, said the Obama administration examined the evidence when states asked for work requirements before, and found them inconsistent with the program’s purpose.

“I don’t think this is an empiricist’s approach,” Mr. Fishman said.

Jared Bernstein, a senior fellow at the Center on Budget and Policy Priorities, and Hannah Katch, a health policy expert at CBPP and a former Senate health policy staff member and a California Medicaid administrator, write Trump’s Medicaid Work Requirement Will Backfire:

Just because President Trump and the Republican Congress were unable to pass health care legislation that would have unwound the coverage benefits of the Affordable Care Act doesn’t mean such attacks are behind us. To the contrary, Republicans are now making an end run around Congress to accomplish one of their harshest goals: kicking economically vulnerable people off Medicaid.

The administration’s new approach — one that no administration before it has taken — is to provide waivers to states that allow them to impose work requirements for Medicaid benefits. Thus far, the Centers for Medicare and Medicaid Services has received requests for such waivers from 10 states. C.M.S. released guidance on Thursday describing how states can institute these work requirements.

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Some of these people will lose coverage because they can’t find jobs to fulfill the work requirements. Others will lose it because they fail to complete paperwork proving they’re working or that they qualify for exemptions. For example, people with mental illness, addiction or chronic disease often struggle to meet bureaucratic demands; in programs that already demand that beneficiaries work, such individuals have often been punished for falling short on work requirements even though they’re supposed to qualify for exemptions.

Instead of requiring states to increase and strengthen coverage, C.M.S. will now allow them to use waivers to promote “upward mobility” or “responsible decision-making.” If those sound good to you, understand that they are known euphemisms for work requirements. The key point, as the Medicaid analyst Jessica Schubel points out, is that neither of those goals align with Medicaid’s mission of providing comprehensive health insurance to low-income people. They would instead, she said, “let states kick people off coverage if they don’t comply with new requirements that have nothing to do with health insurance.”

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It’s also essential to recognize that Medicaid work requirements won’t work. There’s no evidence that Medicaid discourages work, which comports with common sense: You can’t pay rent or buy groceries with health coverage. About 80 percent of able-bodied adult Medicaid recipients are part of working families (that is, either they or their spouses work), and about 60 percent work themselves. Among adults on Medicaid who don’t work and could be subject to the work requirement, more than a third have a chronic health problem or disability, about half take care of their family or go to school, and just under 10 percent can’t find work.

It’s far more likely that Medicaid work requirements will backfire, at least in terms of improving beneficiaries’ living standards. By providing coverage for workers in jobs that are unlikely to provide such benefits, and by helping to stabilize the finances of people with illnesses, Medicaid has been found to help people stay employed or find work.

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By letting states impose work requirements in Medicaid, the administration will hurt many of the very people Mr. Trump said that he wanted to help when he ran for president. And announcing this policy in the wake of the tax overhaul makes the administration’s priorities especially stark: Reductions in coverage will be phased in alongside hundreds of billions in tax cuts for wealthy households and corporations.

Since congressional Democrats cannot stop the administration from issuing waivers, this battle now moves to the states. State legislatures and advocates for low-income families must insist that their representatives and elected officials not go down the path of requesting waivers. [Arizona has already requested a wiver.] Medicaid is working, as are most able-bodied adults who are eligible for it. The administration’s bid to cut the program under the guise of mobility-enhancing work requirements must be seen for what it is.

The Washington Post editorialized last week that Medicaid work requirements are a solution in search of a problem. The New York Times editorialzed, The Trump Plan to Hurt the Poor by Pretending to Help Them.

The Arizona media have barely mentioned the new Medicaid work requirements or that Arizona has requested a waiver.