December 14, 2018
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The main effect of LePage’s, Trump’s Medicaid work rules? Fewer people with coverage.

Andrew Harnik | AP
Andrew Harnik | AP
Vice President Mike Pence meets with Maine Gov. Paul LePage to discuss health care and tax reform in the Eisenhower Executive Office Building on the White House Complex in September 2017.

The Trump administration is inviting states to impose work requirements on people who depend on Medicaid to pay for their health care. Maine, unsurprisingly, is among the first in line.

The Maine Department of Health and Human Services last year sought federal Medicaid officials’ permission to require non-disabled, low-income adults enrolled in Medicaid to work as a condition of receiving coverage. The state needs a waiver from federal Medicaid law so it can impose the requirements.

The federal government has wide latitude to grant states such waivers. Federal law provides for waivers to allow “experimental, pilot, or demonstration” projects that are “likely to assist in promoting the objectives” of Medicaid. Typically, waivers have allowed states to expand coverage to new populations or test out ways of delivering benefits to improve enrollees’ health and save money.

Imposing work requirements does none of that. The clearest result would simply be more people lacking health coverage, and the LePage administration’s application to the federal Center for Medicare and Medicaid Services, or CMS, makes this clear.

Maine DHHS proposes requiring that low-income, non-disabled adults work or participate in training 20 hours a week, volunteer 24 hours a month, or enroll at least half-time as a student in order to receive health coverage through Medicaid. If they don’t comply, they could qualify for coverage for only three months in every three-year period.

The LePage administration is also proposing to charge a group of people earning poverty-level incomes monthly premiums, and to charge them when they use the emergency room for what DHHS determines to be non-emergencies. If Medicaid enrollees don’t pay their monthly premiums, they would lose their coverage after a 60-day grace period. They wouldn’t regain it until they’ve paid all of their missed premiums.

The available research on requiring Medicaid beneficiaries to pay monthly premiums shows that premiums discourage people from enrolling in Medicaid, causing them to go without health coverage.

And while the LePage administration tries to argue in its waiver application that imposing work requirements improves people’s economic circumstances, its own analyses have shown this isn’t the case. Between 2014 and 2015, nearly 6,900 adults lost food stamps after work requirements took effect in that benefit program. While the administration tried to argue the policy prompted more of them to work and caused their wages to grow, employment records show only 34 percent were working a year after losing food stamps, up from 28 percent a year before. On average, their income worked out to less than the federal poverty level for a two-person household.

In its Thursday letter inviting states to impose Medicaid work requirements, the Trump administration argued the policy change advances Medicaid’s objective of providing medical assistance to those who can’t afford it because employment improves health.

“CMS recognizes that a broad range of social, economic, and behavioral factors can have a major impact on an individual’s health and wellness, and a growing body of evidence suggests that targeting certain health determinants, including productive work and community engagement, may improve health outcomes,” read the letter from Brian Neale, CMS’ Medicaid director.

The assumption behind the work requirement policy seems to be that people are purposefully not working so they can receive Medicaid. But a Kaiser Family Foundation analysis released last month showed a majority — 60 percent — of adults enrolled in Medicaid were working. That’s not too different from the nation’s overall workforce participation rate of 62.7 percent.

And 80 percent of adult Medicaid recipients, according to Kaiser, live in families with someone who works. Among those Medicaid recipients who aren’t working, most reported that a major illness, disability or family caregiving responsibility prevented them from working. Others were looking for work. More than 60 percent of the non-working Medicaid recipients were women, according to Kaiser; 17 percent were parents with children under age 6.

In sum, the Trump administration is targeting a poor population that’s not exactly slacking off, and it’s trying to drive more of them to work using a strategy that hasn’t exactly proven effective.

Ultimately, the most obvious effect from imposing work requirements in Medicaid will be to deprive more people of the health coverage they need to live healthy, productive lives.

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