Nine states are planning to implement work requirements for their Medicaid enrollees, following Kentucky, which on Friday became the first place in the country to be approved to create such a program.
Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, North Carolina, Utah, and Wisconsin have submitted their own proposals, though some will have to work with federal officials to make sure their requests fit the guidelines laid out Thursday by the Trump administration. States have varying requests, according to a Washington Examiner review of Medicaid waiver requests filed to the Centers for Medicare and Medicaid Services.
For instance, Indiana, which said it expects its waiver will be approved in the coming days, allows an English as a Second Language class to meet the education requirement. In Arkansas, taking a class for 20 hours a year on healthy living or health insurance would go toward the requirement.
Maine requires 20 hours of work or community involvement, while Kentucky and Indiana don't have any requirements for the first three months of coverage and gradually require more work the longer someone is on Medicaid. Nearly all state proposals appeared to make exemptions for caregivers. Some states, such as Arkansas, would require monthly check-ins while others are less frequent. Kansas, Maine and Utah exempt parents of children under age 6, while North Carolina would exempt any adult with a dependent child.
The age of exclusions also vary, though all children are exempt from requirements. Utah's exclusions begin at age 60, Arkansas' at age 49 and Arizona's at age 55.
Few states released estimates about how the programs would affect Medicaid enrollees. Kansas officials estimate that of the 400,000 covered, 12,000 would face requirements, but that most already were meeting them. Utah said the requirement would apply to about 13,000 enrollees and could reach as many as 6,000 more. It anticipated half already met the requirement. Arizona officials estimate that fewer than 270,000 Arizonans would be affected by the requirements, said Heidi Capriotti, public information officer for the Arizona Health Care Cost Containment System.
A study published in the journal Health Affairs in 2017 projected that as many as 11 million people would fall off Medicaid rolls if work and community involvement programs were to be implemented nationwide. Not every state has expressed interest in implementing requirements, however. Among those that did, the resounding themes in the application documents focused not only on cutting costs but also on the idea that the initiatives would result in people having better lives and becoming healthier.
“State Medicaid directors don’t have a consensus position on whether or not 'work requirements' are the right approach for Medicaid, and appreciate that the guidance provides an option for state consideration, as opposed to a mandate,” Matt Salo, executive director of the National Association of State Medicaid Directors, said in an email. “That said, there is broad interest among states in continuing to encourage and facilitate community engagement, as a strategic goal to improve the health and well-being of recipients.”
Other states considering their own proposals include Mississippi, Ohio, South Carolina, South Dakota and West Virginia.
States that responded to requests for comment said they were waiting for additional details from CMS about changes to their applications. Coming up with rules about work requirements involves state legislatures and public input before a final proposal is sent to CMS.
"CMS has all of the information it needs from Utah right now," Tom Hudachko, spokesman for the Utah Department of Health. "We expect our CMS project officer to send us a review of our request and some suggestions for how it can best fit into the CMS work requirement model."
A CMS official said the agency was working with each state that had submitted applications and was "working diligently toward approval," which it said would include making sure the waivers are consistent with the guidelines.
Medicaid, a program funded by the state and the federal governments, has to be carried out in a certain way, but states are allowed to make changes as long as the federal government signs off on them. Many of these changes are intended to test theories and are sometimes copied by other states. The requirement to work, volunteer or take classes as a condition of enrollment is the latest of these ideas that has gained traction.
States differ in their Medicaid programs because some expanded it under Obamacare to residents who make less than roughly $16,000 a year, while others have not, partly because state lawmakers say they object to the idea of allowing what they have described as "working-age," "able-bodied" adults to receive coverage at no cost. The work requirements may make the program more palatable politically, particularly to Republicans. It also may ease the cost for expansion states, which began paying for part of the Obamacare expansion in 2017. Under Obamacare the federal government will reduce its share of payments to 90 percent of total costs by 2020. For some states, that will mean billions of dollars over time.
North Carolina, for instance, will not go ahead with its waiver unless the state opts to expand the program under Obamacare, according to the state department of health and human services.
Other considerations are at play, including the opioid epidemic. Maine's application does not exempt people who are undergoing treatment for substance abuse, while other states do.
"The department believes that recovery requires a holistic approach, which includes establishing purpose and stability," according to the Medicaid waiver application, which adds that work and volunteering "provides this daily structure and a sense of pride" and that the department didn't believe a "blanket exclusion" was needed. CMS has not said if it will approve the waiver without a carve-out for substance abuse treatment, but Maine is in transition as it works out how to pay for expanding the program under Obamacare.
Beneficiaries who don't abide by state requirements may lose coverage. It's not clear how many people would no longer be enrolled in Medicaid as a result of gaining a job with coverage or as a result of becoming uninsured. CMS Administrator Seema Verma said officials would evaluate the program's success, but said lower enrollment in Medicaid as a result of a shift to private coverage would be considered a positive outcome.
Proponents of the requirements have touted the former, but its critics say that the reporting requirements will become burdensome not only to individual enrollees but to states' administrative budgets. The requirements are likely to face a legal challenge, say pro-Obamacare groups such as Families USA, which called the requirements an "attack" on healthcare after the passage of the Kentucky waiver.