Examining the Changing Face of Medicaid After 54 Years

By Sophie Roe (PO ’19)

On July 30, Medicare and Medicaid turned 54. Interestingly, what began as a federal-state government health care program is now being called a “welfare program.”

Although Medicaid is overseen by the Federal Government, states are granted an incredible degree of discretion to structure and implement the program as they see fit.  The consequence is extreme variation in how Medicaid works and what it means to be enrolled from state to state. A recent and controversial example is the Medicaid work requirement.

“Medicaid work requirements” require beneficiaries to verify that they worked, did community service, or went to school for a designated number of hours (usually 80) each month in order to maintain coverage. As when the Trump Administration’s approval of Kentucky’s work requirement was vacated by a federal district court demonstrated, the mechanism through which states can enact a Medicaid work requirement is called the “1115 Project Demonstration.” Under the Social Security Act of 1115, the Secretary of HHS can “waive specific provisions of major health programs,”[1] allowing states to pilot new, experimental projects and health delivery methods that “promote the objectives of the Medicaid program.”[2] Over the years, 1115 Project Demonstrations have enabled states to use Medicaid in extremely innovative ways: Michigan expanded Medicaid eligibility to children and pregnant women affected by the Flint Lead Exposure Crisis, Oregon transitioned to a regional, value-based payment structure through Community Care Organizations (CCOs), and during the Obama administration, eight states obtained authorization to conduct Medicaid expansion ways not technically permitted by federal law.[3]

In January 2018, the Trump Administration’s Center of Medicaid Services (CMS) released updated 1115 Demonstration guidelines that encourage states to establish “work” or “community engagement” as conditions for Medicaid eligibility.[4] As of today, CMS has approved work requirement demonstrations in 4[5] states, seven states have waivers pending, and one state (Arkansas) has the work requirement currently in effect.

 “Arkansas Works”: The Facts

  • On July 5, 2018, 27,140 low-income adults[6] ages 30 to 49 who did not have Medicaid prior to AR’s Medicaid Expansion had to report that they completed 80 hours of work or community engagement activities between June 1 and July 5 using the DHS Online Portal.[7]
  • By September 5, that number could increase to 93,471. In 2019, all adults ages 19-39 who gained coverage under Medicaid expansion[8] will be required to comply with the work requirement.
  • Individuals who fail to meet the requirement 3 months in a row can lose Medicaid coverage for the rest of the year.
  • The state will spend $1.1 million to implement the work requirement over the next two years, not much relative to the $190 million Kentucky was planning to spend on its entire 1115 waiver before the work requirement was struck down.[9]
  • According to the Urban institute, “8 percent of Arkansas’ Medicaid population, could be subject to the work requirements and are not working.”

Supporters claim that doing work or community service will “improve enrollees health and well-being,” and “help them climb up the economic ladder.”[10]

Cindy Gillespie, a previous health care advisor to Mitt Romney and currently, the director of the Arkansas Department of Human Services (DHS) argued that thanks to state-contracted employment advocacy and outreach organizations, nonworking beneficiaries will “see more and here more about services [job training services][11] available.” Apparently, when the state simply “told” these individuals what resources were available without threatening a loss of coverage, they “didn’t listen.”[12]

Gillespie’s framing of the work requirements calls into question whether these advocacy organizations are actually reaching everyone whose coverage is under threat. For example, are they reaching persons without internet, transportation, or permanent housing?

People who oppose the work requirement argue that Medicaid provides many of the homeless individuals their organizations serve “the means to an end,” an opportunity to get back on their feet. As a federal-state entitlement program, Medicaid is supposed to help people with severe mental or physical illnesses get healthy in order to work. The idea of placing a work requirement on a social safety net health program is not only burdensome and cruel, it’s simply illogical.

As we celebrate Medicaid’s 54th birthday, it is important to take note of what opportunities this administration has opened up, and some states have seized upon, to change what it means to be a beneficiary





[2] https://www.kff.org/medicaid/issue-brief/medicaid-and-work-requirements-new-guidance-state-waiver-details-and-key-issues/?utm_campaign=KFF-2018-January-Medicaid-Work-Requirements-By-State&utm_source=hs_email&utm_medium=email&utm_content=2&_hsenc=p2ANqtz-95kHIeKMAbR_tFge24JnKO-yTD8fIAhyuw5p6MMb2Uy7GlaDp3Fcu1LjGXYVeTvlWqsj9-Q5eYTQqwsfPYXahmPM6A4A

[3] https://www.kff.org/medicaid/issue-brief/current-flexibility-in-medicaid-an-overview-of-federal-standards-and-state-options/).

[4] https://www.kff.org/medicaid/issue-brief/implications-of-work-requirements-in-medicaid-what-does-the-data-say/

[5]Kentucky’s Work Requirement was vacated by a Federal District Court, thus only 3 states currently have a legal work requirement.

[6] For a complete list of exempt populations, see Table 1.

[7] https://www.kff.org/medicaid/issue-brief/implications-of-work-requirements-in-medicaid-what-does-the-data-say/

[8] Extended eligibility to parents ages 19-64 between 17-138% FPL, and newly eligible adults without dependent children ages 19-64 between 0-138% FPL.

[9] http://www.modernhealthcare.com/article/20180601/NEWS/180539982).

[10] https://money.cnn.com/2018/03/05/news/economy/arkansas-medicaid-work-requirements/index.html

[11] Beneficiaries who need employment and training assistance will be referred to the state Department of Workforce Services, which currently helps Supplemental Nutrition Program and the Temporary Assistance for Needy Families (TANF) beneficiaries meet their work requirements.

[12] https://www.google.com/amp/s/www.theatlantic.com/amp/article/563585/

Leave a Reply