Earlier this month, I read about Arkansas Governor Asa Hutchinson’s proposal to change the Arkansas Works Medicaid expansion “hybrid” program, which purchases private insurance for more than 300,000 low-income enrollees throughout the state (see Arkansas Governor Seeks New Restrictions On Medicaid Plan). This measure would require many enrollees to spend a certain amount of hours in a week or month working at a job — or participate in training and activities that lead to employment — in order to continue receiving coverage. Other proposed adjustments include giving the state more control in determining overall eligibility of enrollees and lowering the eligibility cap for the program from 138% of the federal poverty level (FPL) to 100% of FPL (which would take approximately 60,000 people off of coverage via Arkansas Works).
For now, I want to focus on the work requirement. Arkansas Governor Hutchison has said that he wants to align the Medicaid work requirements with the current requirements for the state’s food stamp program, the Supplemental Nutrition Assistance Program (SNAP). To qualify for SNAP in Arkansas, able-bodied adult enrollees have to work, receive vocational training, or volunteer for a charitable organization for a minimum of 80 hours per month. If this proposed change in Arkansas is approved, the new waiver would go into effect January 1, 2018.
This proposal for work requirements is not new or unique to Arkansas. Over the past four years, there have been four states (Arizona, Indiana, Kentucky, and Pennsylvania) that have proposed work requirements as a condition of Medicaid eligibility under their 1115 Medicaid expansion waiver applications. The Centers for Medicare and Medicaid Services (CMS) did not approve these requirements as a condition of Medicaid eligibility in Arizona, Indiana, or Pennsylvania. Kentucky’s waiver approval is still pending (see The Future Of The Non-Traditional Medicaid Expansion Model: A State-By-State Guide). There are three states (Indiana, Montana, and New Hampshire) that currently have voluntary employment programs designed to help beneficiaries find work and receive job training, but Medicaid benefits are in no way tied to participation is these programs (see Medicaid and Work Requirements).
If CMS does approve this approach, what will the impact be on consumers with Medicaid work requirements? There are a lot of contradictory opinions – and often, it comes down to how you view Medicaid. Those who are pro-work requirements think about Medicaid as more of a cash welfare program, like the Temporary Assistance for Needy Families (TANF) program. TANF provided income assistance for needy families, which is tied to state-based work requirements (see What Income Assistance Is Available To Consumers Through TANF & How Does It Vary By State?: An OPEN MINDS Market Intelligence Report). Supporters of work requirements tend to view Medicaid through the same lens and believe that work requirements help consumers end dependence and promote personal responsibility (see Should Medicaid Recipients Have to Work?). Those who oppose the requirements note that good health is a precondition to work and removing health insurance makes it harder to find and keep a job. Others notes that the work requirements would be ineffective and difficult to enforce; and might discourage enrollment in Medicaid, which would increase uncompensated care and safety net expenditures (see Why Medicaid Work Requirements Won’t Work, Work Requirements in Medicaid Won’t Work. Here’s a Serious Alternative, and Work Requirements in Medicaid: a Bad Idea).
Time will bring some clarity on a few key questions. First, what are the specifics of the Arkansas proposal and what do they mean for consumers with behavioral disorders and/or comorbid chronic diseases? Second, if the current Congress provides more “flexibility” to the states in Medicaid eligibility requirements, what are the range of work requirements that consumers might see and how will that impact the ability to get Medicaid coverage in the state?
My colleague, Gary Humble, OPEN MINDS Advisory Board member and Executive Director of Pinnacle Partners in Cleveland, shared a few perspectives on this issue with me:
I know there has been quite a bit of heated debate around the country about requiring Medicaid members paying for a portion of their health care services, whether through a monthly premium or in the form of co-pays for certain health care services.
In my mind, the question comes down to what is the end goal of these proposals? Most of the health care debate has been centered on health insurance coverage. We need a more robust discussion of health care in its totality that includes health care delivery, benefit structures, and health care financing.
We need to provide incentives for behaviors that will lead to the outcomes we want to see accomplished. From the member perspective, that means providing incentives for behaviors that moves that member towards a healthier lifestyle. How about Health Care Savings Accounts (HSAs) that can be used for alternative medicine services, gym memberships, or purchasing fresh fruits and vegetables instead of processed foods? How about cash payments to Medicaid clients’ HSAs who proactively alter their lifestyle for the better, reducing their overall health care costs during a specific period of time?
Although there are reforms that are under way in our system, until we look more globally at health care, most attempts to “reform” it will just be window dressing and will do little long term to bend the cost curve.
Since the U.S. Congress gave state’s the authority to receive a waiver to Medicaid rules and regulations in 1983, Medicaid programs have adopted over 500 waivers, which have made state Medicaid programs increasingly disparate. Currently, there are 408 active, approved waivers, the majority of which are 1915(c) home and community-based services waivers (see What Are Medicaid Waivers & Why Do They Matter?: An OPEN MINDS Market Intelligence Report and What Provisions Of The Social Security Act Are Related To Health Care?: An OPEN MINDS Market Intelligence Report). The work requirement is just one more variant on this theme.
I think this topic will be front and center when Congress returns to the issue of health care. The failed (or perhaps only paused) American Health Care Act proposed allowing states to “condition medical assistance to a nondisabled, non-elderly, nonpregnant individual under this title upon such an individual’s satisfaction of a work requirement” (see American Health Care Act of 2017: Manager’s Amendment—Policy Changes). And even without a change in federal legislation, the Trump administration is free to approve the proposed Medicaid plans for work requirements that were disallowed under the previous administration (see Waivers Represent A Quieter Way For Republicans To Change Health Care).
Wondering what to make of this – and how to plan in a time of policy uncertainty? Mark your calendars now for The 2017 OPEN MINDS Management Best Practices Institute, in Long Beach, California, where my colleague Joe Naughton-Travers, Senior Associate, OPEN MINDS will lead the session, “Preparing For An Uncertain Future In Health & Human Services: The OPEN MINDS Guide To Scenario-Based Strategy Development.”