Kentucky’s decisions around operationalizing its Medicaid waiver imposing work requirements on beneficiaries "will be critical to determining the impacts of these provisions on the health and well-being of low-income adults," according to a brief by the Urban Institute. The brief also warns that the waiver may lead to confusion and even more enrollment barriers placed upon nonexempt individuals. The brief was undertaken following the January 2018 CMS letter to state Medicaid directors endorsing the ability of states to impose "community engagement" (work) requirements on Medicaid beneficiaries and approval of the Kentucky HEALTH waiver application (see Trump’s CMS endorses Medicaid work requirements, January 11, 2018). The waiver has since been challenged by a class of Kentucky Medicaid beneficiaries seeking declaratory relief from the work requirements (see Class action says ‘radical’ Kentucky Medicaid work requirement is unlawful, January 25, 2018).
Exemption groups. According to the brief, 653,000 nonelderly adults were enrolled in Kentucky’s Medicaid program in 2016, with 122,000 receiving supplemental security income (SSI) and therefore exempt from the waiver requirements. Based on data from the U.S. Census Bureau’s 2016 American Community Survey (ASC), the institute was able to group Kentucky Medicaid enrollees into three groups, described below, and identified characteristics of each group that may affect the work requirements.
- Group 1: Approximately 174,000 enrollees will likely be exempt from the work requirements because they are in school or are the primary caregiver of either a dependent child or a household member receiving SSI. (This will likely be expanded to include pregnant women or medically frail individuals.) The brief noted that 72 percent of the group is under age 40 and 39 percent of this group is already working. Despite working, the average worked per week was 31 hours, and about half of individuals working did not work for the entire year.
- Group 2: Approximately 169,000 enrollees will potentially be subject to work requirements because they do not fall under any of the exemptions, but are working. The average age of this group is 38 and 53 percent are male. Around 64 percent of this group worked at least 50 weeks and 20 hours per week in the previous year (and still do not meet the minimum threshold for the "community engagement" requirements of working 80 hours per month throughout the year, and may face interruptions in Medicaid coverage).
- Group 3: Approximately 188,000 enrollees will be subject to work requirements because they do not fall under any exemptions and are not working. The average age is above age 50. This group is most at risk for losing Medicaid coverage. No enrollees in this group receive SSI but 41 percent have at least one serious health limitation themselves, 61 percent have at least one member of their household with at least one.
Barriers. The study noted regarding Group 2, that "many enrollees will have difficulty finding work, participating in community engagement activities, and documenting their fulfilled hours." Among all the groups, there are barriers that will potentially affect the ability to meet or document the work requirements. The study looked at the following barriers: (1) no access to vehicle or internet; (2) less than a high school education; (3) serious health limitation; and (4) lives with someone who has a serious health limitation. Looking at each group, 76 percent of those in Group 3 have one of these barriers, 57 percent in Group 1, and 55 percent in Group 2.
Limitations to analysis. Several limitations of the brief were provided that may have led to some of the enrollees being misclassified into the wrong group: (1) the waiver’s language defines exemptions only ambiguously; (2) all school-going adults considered as meeting full-time status; (3) statistics regarding pregnant women were not accounted for in ACS; and (4) number of work hours surveyed in ASC may not align with waiver requirements.
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