MHW: States Favoring Medicaid Work Mandate Continue to Face Roadblock in Courts

States Favoring Medicaid Work Mandate Continue to Face Roadblock in Courts

Mental Health Weekly April 8, 2019


The debate over whether work requirements should be imposed on Medicaid beneficiaries shows no signs of easing, with some states’ efforts to impose work provisions consistently losing in the federal courts while the Trump administration continues to encourage states to move in this direction.


A federal judge in the District of Columbia last month blocked for a second time a Kentucky work requirements initiative that has not yet been launched, while also rejecting Arkansas regulations imposed last June that have resulted in more than 18,000 Medicaid beneficiaries losing their coverage. But also last month, the Centers for Medicare & Medicaid Services (CMS) issued guidance to states on implementation and evaluation of such initiatives, seeking to clarify how work requirements can best be incorporated into Medicaid waiver programs.


Moreover, The Washington Post reported that upon learning of the court rulings affecting Kentucky, Arkansas and potentially other states, CMS Administrator Seema Verma said, “We will continue to defend our efforts to give states greater flexibility to help low-income Americans rise out of poverty.”


Mental health advocates have argued that imposing work requirements on Medicaid expansion populations will be particularly damaging to individuals with mental health and substance use disorders. Advocates see the potential of losing one’s health care coverage as a major impediment to being able to hold a job.


“Even if the work requirements have exceptions for people with disabilities, the way they are explained to people, or not explained, ends up having  people lose  coverage  when they  shouldn’t  even  be  subject  to work requirements,” Chuck Ingoglia, senior vice president of policy and practice improvement at the National  Council  for  Behavioral  Health, told MHW.


Philosophical difference

The most recent opinions issued by U.S. District Court Judge James E. Boasberg help to illustrate the philosophical divide that characterizes the discussion of Medicaid work requirements.


On two occasions since last year, Boasberg has concluded that the federal government acted in an arbitrary and capricious manner in allowing Kentucky to proceed with its plans (see MHW, July 16 and July 2, 2018). The judge suggested in his most recent opinion in the Kentucky case (a 48-page ruling issued last month) that the federal government and some states are seeking to impose requirements that are not in keeping with the Medicaid program’s purpose to provide health coverage to poor and vulnerable populations.


In a separate opinion, Boasberg ruled that the regulations that have implemented Arkansas’ work requirement since last June cannot stand and must be subject to reexamination by the federal government. The requirements have resulted in around 18,000 people losing coverage last year for failing to comply with requirements to work, undergo training or volunteer for 80 hours a month. This group likely would include both those who did not fulfill the requirements and those who simply failed to report what they did achieve.


“Many didn’t know they had to file, and many didn’t know they had to file every month,” said Ingoglia, who will become the National Council’s president and CEO in June.


“At the time Arkansas asked for permission, they knew it would result in people losing coverage,” Ingoglia added. But the numbers are higher than expected at this point, and this is concerning because Ingoglia says Arkansas arguably was one of the most thoughtful states in its planning for this component of the Medicaid waiver.


In general, however, it is the National Council’s position that “the unspoken purpose of imposing work requirements is to get people off Medicaid,” Ingoglia said.


According to news reports in Arkansas, Gov. Asa Hutchinson has urged the Trump administration to appeal the judge’s ruling invalidating the state’s work requirements. At the same time, he has asked state legislators to vote to preserve the state’s waiver program so that the issue of work requirements can remain active. The requirements apply only to the state’s Medicaid expansion population.


At press time last week, it appeared that state legislators were moving in that direction. At the same time, some Democrats in the legislature were trying to advance a mea- sure that would reinstate all of the beneficiaries who lost coverage last year under the work requirement provisions. These individuals were invited to reapply for coverage at the beginning of this year, but so far only around 2,000 have reenrolled.


Some states in limbo

According to the National Council, nine states have received federal approval to impose work requirements in Medicaid, and seven more are awaiting approval of their plans. How events unfold in states where plans have been rejected by the court and must be reexamined in Washington will likely have a major impact in some states that are still considering Medicaid expansion. Ingoglia said that in some reluctant states such as Kansas and Virginia, it is unlikely that leaders will pursue Medicaid expansion at all if work requirements can’t be included for the expansion population.


Leaders in California took a much different approach to the work issue last year, enacting a law stating that any work provisions for individuals receiving subsidized health care services must be voluntary in nature (see MHW, Oct. 1, 2018).


While the National Council in its analysis of work requirements remains, in its words, “vehemently opposed to these harmful policies,” a silver lining in the CMS’s recent issuance of guidance to states might be that it could eventually bring more of an evaluation element into the programming. Advocates would expect that bringing in honest evaluators would help to illustrate some of the ill effects of imposing these requirements, and how the mandates contradict the purpose of the Medicaid program.


These issues remain critically important as some states reconsider whether imposing work requirements represents a viable strategy, while some of the strongest supporters of work mandates would like to extend that requirement to the entire Medicaid population, not just the expansion group. •