With the announcement that Kentucky will be the first state to receive approval from the Trump administration to require many Medicaid recipients to have a job or do volunteer work in order to maintain benefits, it also becomes the first state to be the subject of a federal lawsuit to block these new rules. The lawsuit, filed Wednesday in the US District Court for the District of Columbia by three nonprofit groups, is the first legal challenge of a Medicaid waiver granted by the Trump administration. We expect more lawsuits to follow as more states sign on.
And, to add more intrigue to who gets to keep their Medicaid coverage and who does not, another twist came with the announcement that if you lose your health coverage because of the Kentucky work requirement, you can regain it by passing a health or financial literacy test. All of this adds to the doubts about the motivations for these actions. Is the goal to help low-income people get the health care they need, or to have as few people covered as possible? The answer may depend on who you ask.
Back in 2017, when the Trump administration was still struggling with its approach to health care and the debate over the American Health Care Act was in full swing, a proposal was on the table for adults ages 19 to 64 to either work or take part in approved job search or training program to receive Medicaid coverage. Leighton Ku and Erin Brantley, writing in Health Affairs, explores the impact of such a program on those who would be required to participate.
Nationwide, about 22 million adults covered by Medicaid (58 percent of all adults on Medicaid) could be subject to the work requirement, as specified above. Fifty percent of the 22 million are already working, 14 percent (3 million) are looking for work, and 36 percent (8 million) are neither working nor looking for work.
About 11 million Medicaid enrollees, including those already looking for work, would be at risk of losing coverage if these requirements were imposed nationwide. This equals more people than the population of most US states and about 15 percent of the 74 million people using Medicaid. Some of those looking for work might count as fulfilling job search requirements, and some of the others might enroll in job training programs. Nevertheless, based on the history of work requirements in cash welfare, substantial coverage losses are likely.
Ku and Brantley note that many at risk of losing coverage have serious health problems. Sixty-three percent are women, more than half are from communities of color (while 44 percent are non-Hispanic whites), and these populations are marked by educational inequities, with an observed lack of high school and post-secondary education. Many are already caring for a disabled family member or have a disability themselves. These do not seem to be people ready to take on a work requirement of 20 or more hours a week, nor are they prepared to take on a financial literacy or health literacy test—although they might benefit from the information.
Kentucky has become the poster child state for this program. It experienced explosive growth under Medicaid expansion as a part of Obamacare. Medicaid now covers more than one-fourth of the state’s population. Kentucky’s Governor Matt Bevin is looking for ways to change that.
Bevin and other Republican leaders say the state can’t afford that. He said it is his goal for Medicaid to be covering 95,000 fewer people in five years, because that means those people will have gotten jobs that pay them so much money they are not eligible for Medicaid anymore.
“Nobody will be removed at all. Nobody. Some will choose not to participate and some will chose to participate and will ride this thing right out of Medicaid, and that’s exactly what it is there for,” he said.
State officials expect the new rules will cause 95,000 people to lose their Medicaid coverage for a variety of reasons over the next five years. And in an unusual pre-emptive move, Republican Gov. Matt Bevin has signed an executive order that would repeal the state’s expanded Medicaid program if any part of the new rules is struck down in court. If that happens, it would end health coverage for more than 400,000 people.
But then, there are always the health and financial literacy tests to give those who cannot meet the work requirement a way back into Kentucky’s Medicaid system. According to the New York Times, some health experts are not thrilled with this option.
For one thing, many Americans, not just those who seek Medicaid, struggle with health and financial literacy. And to some, literacy quizzes—however well intentioned—evoke the tests used to impede voting registration of black Americans in the Jim Crow South.
“Requiring people to pass a health literacy course to get care—care for conditions that might prevent them from passing—is just expensive, punitive and cruel,” said Atul Gawande, a surgeon and a health care researcher with the Harvard T.H. Chan School of Public Health. “It serves no health benefit whatsoever. You have to be concerned about requirements like literacy tests, which states have a bad history of applying selectively and arbitrarily.”
But Kentucky officials say these courses were always meant to be a means of support for people and a way to help improve both their health and finances. And so, the debate continues.—Carole Levine