Rebecca Pifer
Sept. 12, 2018
Dive
Brief:
- Michigan
will roll back expansion of its Medicaid program unless it is allowed to
institute controversial work requirements for the program, according
to an application Gov.
Rick Snyder, a Republican, sent to HHS this week.
- Under the
proposal, beneficiaries will be required to either work, volunteer, attend
job training or engage in other health-promoting activities for a minimum
of 80 hours a month in order to keep their coverage, along with tracking
and logging their progress in monthly verifications to prove they are
complying with the requirements. The proposal includes 12 exemptions for
populations such as pregnant women and those who are caregivers for
children under 6.
- Approval for the extension request
is being sought for early 2019, with a slated program introduction between
six months to a year later. To date, four states (Arkansas, Indiana,
Kentucky and New Hampshire) are imposing work requirements for Medicaid
and seven (Maine, Kansas, Arizona, Mississippi, Wisconsin, Utah and Ohio)
have submitted waiver applications.
Dive
Insight:
The
application is likely to be approved, as CMS has made work requirement
implementation a priority since the beginning of this year and
the policy has quickly become a linchpin for the current administration. In a
10-page letter to state Medicaid
directors, the agency urged them to test programs that include work
requirements as a condition for eligibility and, so far, has approved them in
four states.
Michigan's
proposal impacts beneficiaries with income between 100% and 133% of the federal
poverty level who have been eligible for or enrolled in Medicaid for four
years. Those who do not meet the program's healthy behavior, work or
cost-sharing requirements will be notified 60 days before the end of their
fourth year on Medicaid that their coverage will be terminated until they
comply with the new strictures.
The
state expanded Medicaid in 2014 under the Healthy Michigan Plan (HMP), which
granted coverage to more than 1 million low-income citizens and currently
enrolls roughly 655,000 people. The introduction of work requirements is meant
to "empower individuals" to improve their health by promoting
"accountability, self-sufficiency, and independence from public
assistance," according to the application, which also touts the positive correlation between
income and health.
The
petition similarly posits the new stipulations will help beneficiaries realize
the mental and physical health benefits associated with gainful employment,
along with providing future opportunities to obtain insurance through an
employer or the federal marketplace.
Yet
the many critics of work requirements point out that most Medicaid recipients
who can work are already doing so, and that instituting and tracking work
requirements will heap additional administrative burden onto an already-taxed
system. Two recent JAMA studies found evidence backing up their opposition.
The first found that,
among the 11 states with submitted waiver applications, only 3.9% to 29.2% of
Medicaid-eligible individuals were subject to proposed work requirements. In
that subset, only 0.3% to 5.4% were not meeting those requirements, bringing up
the question of whether the cost of implementation is justified by the work
requirements' "narrow projected reach."
The second study, also
published in JAMA and building off the former's findings, estimated changes in
Medicaid enrollment and spending if work requirements were applied on a
country-wide scale. If that were to happen, 2.1 million beneficiaries would be
at risk of losing coverage, representing 2.8% of current Medicaid enrollees and
accounting for a mere 0.7% of Medicaid spending. Yet, the study's authors
pointed out, these minimal savings would "likely come at substantial cost
in terms of human health" due to a potential spillover effect,
wherein exempt Medicaid enrollees lose their coverage because they're unable to
comply with stringent documentation requirements for reporting their work hours
or reason for exemption as frequently as every month.
The
murky outcomes of the policies caused a federal judge to invalidate Kentucky's work
requirements in late June, calling their institution "arbitrary
and capricious." Kentucky was the first state to receive approval to
test work requirements. U.S. District Judge James Boasberg wrote in his ruling
that the government never adequately considered whether the requirements
"would in fact help the state furnish medical assistance to its
citizens," a setback to the administration's aim to link benefits to
employment.
In
response, Kentucky halted non-emergency medical
transportation, along with dental and vision coverage for Medicaid
patients, claiming it could not afford to pay for those programs if its waiver
was not approved. Following pushback from social advocacy groups, the state
reluctantly reinstituted the benefits.
Arkansas,
which started kicking thousands of people off Medicaid for failing to comply in
July, is currently undergoing similar litigation. Eight more states are waiting
on the outcome of their waiver application, including new entrant
Michigan.
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