Feb 14

The Health 202: Medicaid plans: We’re not ‘hyperventilating’ about work requirements


Guess who’s not fretting over making low-income Americans work or volunteer in return for government health benefits? The Medicaid insurers covering them.

“I think some of the heavy breathing about how terrible work requirements are going to be is over the top,” Jeff Myers, president of Medicaid Health Plans of America, the country’s largest association of Medicaid plans, told me last week.

There has lately been a frenzy of pushback from Democrats and progressives against the Trump administration’s unprecedented move to allow states to enact work requirements as a condition of receiving benefits. Some red states are imposing such requirements for the first time in the program’s five decades, following the failure of the GOP Congress to repeal and replace Obamacare — which expanded Medicaid in many states.

Last month, the Centers for Medicare and Medicaid Services issued guidance saying states may require non-disabled Medicaid recipients to work, volunteer or undergo job training to participate in the program. Out of a dozen states that have applied for work requirements, CMS granted Kentucky’s request last month and on Friday gave the go-ahead to Indiana, my colleague Amy Goldstein reports.

Because this is a pioneering move for CMS — the Obama administration rejected work requirements, saying they were inconsistent with Medicaid’s objectives — it has incited spirited applause from the political right but loud groans from the left. House Minority Leader Nancy Pelosi (D-Calif.) called work requirements a “shameful violation of the letter and spirit of Medicaid” when the guidance was initially issued.

“This mean-spirited decision will have a particularly damaging impact on women, including women currently taking care of seriously ill family members and those who have chronic health conditions of their own,” Pelosi said.

Last week, Frederick Isasi, executive director of the liberal consumer health lobby, Families USA, called Indiana’s waiver “a profound and deeply saddening departure from our nation’s commitment to the health of our families.”

Yet given the small number of enrollees likely to be affected by the work requirements, the uproar may be premature. Myers says he’s watching states closely to see exactly how they implement work requirements. But he feels that if done the right way, such requirements could give some recipients — but only a small number of them — a needed boost toward employment.

“Most people probably won’t be covered by this work requirement,” Myers said.

Members of MHPA contract with states to cover the 74 million Americans who rely on Medicaid, the federal government’s primary health insurance program for low-income individuals. It’s their plans that stand to lose customers if work requirements prompt a reduction in Medicaid enrollment, as many critics predict. Myers acknowledges that’s a likely effect — after all, enrollment dropped when work requirements were introduced to welfare in the 1990s — but he’s expecting only a minimal effect.

“We’re not hyperventilating that millions of people will get thrown off the rolls,” Meyers told me. “We just want to make sure as states do this, they understand there is a cost involved.”

Why might the effect be limited? For one thing, the majority of Medicaid recipients work or cite some valid reason they don’t, such as a disability or illness, acting as caregivers or attending school. Forty-two percent of Medicaid recipients work full time and 18 percent work part time, according to population survey data analyzed by the Kaiser Family Foundation.

That’s a top argument among critics for why they don’t think work requirements are needed. But it’s also a reason the requirement probably won’t have a massive wave effect on the program — most recipients either work or have some other life circumstance that prevents them, exempting them from the new requirements.

In addition, CMS is giving wider latitude than many were expecting to ensure states provide plenty of exemptions from a work requirement, moving to broadly define what constitutes “work.” For example, the agency in its guidance said those caring for children or undergoing substance abuse treatment could be exempted from working. So could be the 10 million people on Medicaid who have a disability.

And work doesn’t have to mean a paying job, according to the administration. States could also count job training, job searching, volunteer work or education as satisfying the requirement.

It’s still true that imposing more rules on government benefits increase the likelihood that even eligible people won’t be able to sign up because of higher barriers. Kentucky officials have predicted between 90,000 and 95,000 fewer people will be on Medicaid by the end of the state’s five-year waiver period — although that’s only a fraction of the more than 2 million Kentucky residents enrolled in the program.

Tom Miller, a health-care fellow at the conservative American Enterprise Institute, estimates work requirements might affect 20 to 30 percent of the Medicaid population at most.

“The reality is these are marginal things,” Miller said. “You can do this for a smaller fraction of the entire Medicaid population — you’re not going to nudge a large number of folks into full-scale work.”

Critics view diminished Medicaid rolls as a negative, but remember that conservative proponents view it as a victory. The idea, they’ve emphasized, is to make Medicaid a temporary safety-net program with incentives to propel people up the economic ladder.

“True compassion is lifting Americans most in need out of difficult circumstances,” CMS Administrator Seema Verma wrote in an op-ed published in The Post on Sunday.

Myers’s major concerns around these new requirements are logistical in nature. He wants to make sure states don’t impose new burdens of oversight on plans as it’s the states that have traditionally handled enrollment qualification. And he wants safeguards to minimize churn in the program so Medicaid recipients don’t find their care disrupted.

To Myers, the devil is in the details. Back in the 1990s, when work requirements were first added to welfare, enrollment in the Temporary Assistance for Needy Families program declined while job participation increased, especially among low-income single mothers (although the 2001 recession stalled much of that progress), said Ron Haskins, a senior fellow for economic studies at the Brookings Institution.

But Haskins and Myers, too, stress that success varied widely among states, depending on how good they were at helping TANF participants find work. With the new Medicaid rules, states face a lot of decisions about how to implement the requirements, how to enforce them, how broad their scope should be and how to help people fulfill them. The Trump administration is expected to respond to waiver requests from perhaps as many as 10 more states to implement work requirements.

“This is what I think the people talking about work requirements are missing,” Myers said. “There are all kinds of granular decisions to be made at the state level before this can even be implemented.”

AHH: Enrollment in religious health-care sharing ministries has skyrocketed, especially in states whose Affordable Care Act marketplaces have been plagued by spiraling premiums and reduced competition, Politico’s Paul Demko and Renuka Rayasam report. Only about 150,000 individuals were enrolled in such faith-based plans when the ACA was passed eight years ago, but the nonprofit groups that offer these plans say they now have more than 1.1 million members.

“What was once a fringe idea, limited to devout Evangelicals and small Mennonite churches in more rural parts of the country, has found acceptance with a segment of the population for whom the government safety net is unavailable and the free market options are unaffordable,” Paul and Renuka write. “As more people look for cheaper alternatives to health insurance, they are stumbling on ministry plans to escape Obamacare’s requirements and state oversight, but still satisfy the law’s individual mandate which, despite its repeal in the recent tax overhaul, remains in effect until 2019.”

OOF: There’s no clear evidence that radiation from cellphones causes cancer in humans. That’s after a $25 million National Institutes of Health study that found while exposure to cellphone radio-frequency radiation led to a higher risk of tumors, DNA or tissue damage and lower body weight in some groups of rodents, there are no clear implications for human health, our colleague Ariana Eunjung Cha reports. The study of 3,000 test animals is believed to be the most comprehensive assessment of the health effects of such radiation on rates and mice.

“The strongest finding in the new study involved male rats…that developed tumors in the nerves surrounding their hearts,” Ariana writes. “The experiment involved placing rats and mice into special chambers and exposing them to levels of radiation that mimic 2G and 3G phones, which were standard when the study was launched, for nine hours a day.” Even the lowest levels of radiation used in the study were much higher than the maximum exposure a frequent cellphone user would get.

John Bucher, a senior scientist at the National Toxicology Program, said “at this point we don’t feel that we understand enough about the results to place a huge degree of confidence in the findings.” The Food and Drug Administration issued a statement saying “evidence that whole body radio-frequency energy exposures given to rats or mice in the study actually caused cancer in these animals” is mostly “equivocal or ambiguous.”

Asked if he had changed his cellphone use as a result of the study, Bucher said: “no.”

OUCH: The Department of Health and Human Services appears to have blacklisted a reporter from the trade publication Modern Healthcare for refusing to delete three sentences from a story that Seema Verma, administrator for the Centers for Medicare and Medicaid Services, didn’t like, according to an account from the Association of Health Care Journalists.

Reporter Virgil Dickson got pushback from CMS after publishing a story a few weeks ago about the abrupt resignation of former Medicaid official Brian Neale, reporting that his departure was prompted by a disagreement with Verma. Dickson says he was told by an agency spokesman he’d no longer be allowed on CMS press calls unless he changed the story.

“Dickson believed the agency was making good on its threat on Thursday when, he said, his phone went mute during a CMS press call and a woman’s voice told him he was not allowed to participate,” AHCJ vice president Felice Freyer writes. “An editor later confirmed with CMS officials that he had been banned from press calls, Dickson said….But after AHCJ sent CMS several questions about the incident, an agency spokesman on Saturday evening emailed a one-sentence reply: ‘No reporters have been banned by CMS.'”

The incident underscores rising tension between HHS and some mainstream media outlets, which, as I noted in Friday’s Health 202, have been recently left out of press calls announcing major initiatives, including Medicaid work requirements.

— Sen. Marco Rubio (R-Fla.) is teaming up with Ivanka Trump to marshal Republicans behind an issue Democrats have typically supported: paid family leave. Politico’s Seung Min Kim reports Rubio is floating allowing people to draw Social Security benefits for family leave and then delaying their checks when they hit retirement age. Under this approach, a person who would begin receiving full benefits when he or she turns 67 years old but wants to take six weeks of paid leave would have to wait an extra six weeks after his or her 67th birthday to start getting Social Security checks.

“Capitalizing on President Donald Trump’s endorsement of the idea in his State of the Union address, Rubio is trying to marshal Republicans behind a plan that would neither impose a mandate on employers nor raise taxes to pay for it — two hurdles that have long halted the GOP from embracing paid family leave,” Seung Min writes. Rubio is still in the early stages of crafting a specific plan, but he and Ivanka have recently exchanged emails about it, and Sen. Mike Lee (R-Utah) has also pitched the idea to the president’s daughter, Seung Min reports.

“That’s a new idea for Republicans who still identify it as something that comes out of the left,” Rubio said. “Forcing companies to provide it is perhaps an idea that finds its genesis on the left, but the notion that pregnancy should not be a bankruptcy-eliciting event is one that I think all Americans should be supportive.”