HHS data highlights negative effects of work requirements

Twenty-three states asked for approval for work requirements, and 13 were approved under the Trump administration

The Department of Health and Human Services building in Washington. (Caroline Brehman/CQ Roll Call file photo)
The Department of Health and Human Services building in Washington. (Caroline Brehman/CQ Roll Call file photo)
Posted March 11, 2021 at 11:10am

New Department of Health and Human Services data shared exclusively first with CQ Roll Call shows that efforts by states to seek work requirements or capped funding result in reduced enrollment and access to care.

The report looks specifically at Section 1115 waivers, which are used to test new types of Medicaid and Children's Health Insurance Program demonstration projects at the state level. Traditionally, these waivers had been used before the Trump administration to expand access to care for subsets of the population.

The Trump administration pushed policy changes to allow states to apply to implement work requirements or seek capped funding in exchange for added program flexibility.

"While one of the stated motivations for several of these demonstration features has been the desire to improve beneficiary health, the loss of coverage evident in multiple studies of these policies suggests they carry a significant risk of having the opposite effect – harms to access to care and adverse health effects," the report reads. "Given the strong evidence linking health insurance coverage to positive health and economic outcomes, policies that lead to loss of Medicaid coverage, increase rates of uninsurance, and heighten barriers to medical care can have significant negative public health consequences, particularly during emergencies such as the current pandemic."

Medicaid work requirements in New Hampshire and Arkansas are also the subject of a Supreme Court case that was scheduled for oral arguments on March 29, but on Thursday morning, the court removed the Medicaid work requirements case from its March calendar. In February, the Biden administration filed a brief to the Supreme Court asking to vacate oral arguments, saying work requirements do not promote the objectives of the Medicaid program.

[Biden uses executive orders to address COVID-19, other health care issues]

The new HHS document also comes on the heels of a January executive order from President Joe Biden calling for HHS to review policies related to Medicaid or the 2010 health law that could cause reductions in coverage. It specifically singled out work requirements, healthy behavior incentive programs, health savings account-like arrangements, and financing changes like modified block grants.

The HHS report released Thursday states that 23 states asked for approval for work requirements, and 13 were approved under the previous administration. Of those 13 policies, four were blocked in court, though no work requirements can penalize individuals during the public health emergency under a separate policy.

Arkansas' implementation of work requirements resulted in 18,000 individuals losing coverage in 2018, and data in this report suggests that New Hampshire's policy would have dropped 17,000 enrollees if it had not been blocked by a lower court. It also shows that 80,000 individuals in Michigan's Medicaid program could have lost coverage without court intervention.

The work requirements programs, which differ in their details, were supported by Republicans who said they encouraged individual responsibility and pushed recipients to search for jobs.

Other experts and medical groups have also voiced concerns about Medicaid work requirements.

On Wednesday, a group of 71 deans, chairs and experts in health law, public health and health policy filed a Supreme Court brief in opposition to the requirements.

"While States have options to expand eligibility and coverage, they cannot impose eligibility or coverage restrictions not authorized by law," the brief says.

Last month, 15 groups including the American Cancer Society Cancer Action Network, American College of Obstetricians and Gynecologists, and Catholic Health Association of the United States, also filed a brief saying the requirements would have negative effects on the state's Medicaid populations.

More than half of low-income Americans live in households where an individual has lost a job or received a pay cut during the pandemic.

"Obstacles to finding new employment have likely grown even larger during the pandemic-related economic downturn of the past year, particularly since job and income losses have been highest among low-income and minority workers, who are disproportionately enrolled in Medicaid," the brief reads.

The report also included data showing health savings account-like arrangements and other so-called healthy behavior incentives can be confusing for enrollees to navigate, which has resulted in some disparities especially for racial and ethnic minorities.

The brief also points to concerns about capped funding for Medicaid, though this has not been implemented anywhere yet, and warns that Medicaid has been especially important during the pandemic. Opponents of capped funding worry it could result in enrollment cuts or reduced benefits for enrollees.

It acknowledges that Oklahoma withdrew its waiver application, which would have sought a capped amount of Medicaid funding in exchange for more program flexibilities. Tennessee has not implemented a similar waiver that was approved in the final days of the Trump administration and some updated aspects of the application are still under review.

"There is no evidence to date on the impact of a capped federal funding model on coverage or access to care among program beneficiaries," the report reads.