Less than two months after the Trump Administration announced a policy change allowing—and even encouraging—states to implement work requirements in their Medicaid programs, CMS has approved three state waivers that include reporting on beneficiary employment. In the New England Journal of Medicine, Boston University professor Nicole Huberfeld, whose scholarship focuses on the role of federalism and spending power in Medicaid, questioned the legality of the administration’s new interpretation and policy change. Huberfeld argues that work requirements are inconsistent with purposes of the Medicaid Act, which she says has the goal of providing eligible beneficiaries with medically necessary care, not ending dependence on the government like welfare programs do.
Medicaid eligibility overview. Many Medicaid beneficiaries become eligible because they are disabled, elderly, pregnant, or young children. The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) expanded Medicaid eligibility to include childless, nonelderly, nondisabled adults earning up to 138 percent of the federal poverty level, or approximately $16,000/year for an individual. Some opposition to expansion has centered on allowing low-income individuals who are "able-bodied" to be covered by Medicaid; the ACA provides subsidies to low-income individuals who purchase health insurance on the exchange, but only to those earning up to 100 percent of the federal poverty level. In some states that did not expand Medicaid under the ACA, non-disabled individuals making less than 100 percent of the poverty level are unable to afford coverage, because the ACA presumed Medicaid expansion coverage for them.
Work requirements. For the first 58 years of the Medicaid program, CMS (and its predecessor federal agencies) did not allow states to implement work requirements as a condition for beneficiaries. In January 2018, however, CMS announced that the agency would support demonstration projects testing work or community engagement requirements (see Trump’s CMS endorses Medicaid work requirements, January 11, 2018). Three such demonstration projects have been approved to date, all in states that expanded Medicaid eligibility under the ACA: Kentucky, Indiana, and Arkansas.
Contrary to purpose? Huberfeld wrote that work requirements are not in furtherance of the goals of either the Medicaid Act or the ACA. The Medicaid Act’s purpose is to ensure that eligible beneficiaries are provided medically necessary care by the states. The ACA’s goals included removing barriers related to obtaining health insurance coverage, such as additional charges for preexisting conditions. According to Huberfeld, work requirements likely do not further these goals—there is research correlating income and health, but she wrote that there is not research indicating that working causes good health. Similarly, individuals may be trapped where the lack of Medicaid prevents employment, which in turn prevents them enrolling in Medicaid. Lastly, Huberfeld questioned whether CMS even has the authority to approve work requirements, because the agency’s authority is promoting health and well-being, not employment. She concluded that work requirements are an unlawful reinterpretation of the purpose of Medicaid, and expects that it will harm the health of beneficiaries who are disenrolled under work requirements.
Companies: New England Journal of Medicine; Boston University
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