Advocates to feds: Don’t let Indiana impose Medicaid work requirement

By Maureen Groppe

WASHINGTON – Indiana could become the first state to require some Medicaid recipients to work, but it is facing a flood of opposition from health groups, advocates for the poor and others.

Public comments filed with the federal government have been overwhelmingly against the idea — even as Congress debates whether to give states more leeway in running their Medicaid programs, along with a lot less funding.

Critics say a Medicaid work requirement will shift funds from providing health care while creating a new bureaucracy that will lead to people being denied care without significant increases in employment.

“A work requirement is just another way to kick people off of Medicaid,” wrote a recipient who said a mental illness makes it difficult to find and keep a job.

Opponents also accuse the state and federal governments of not following the rules and rushing Indiana’s request through the approval process. They say Indiana submitted its request before completing the required public comment period in the state.

Thefederal Centers for Medicare and Medicaid Service, which is headed by former Indiana health care consultant Seema Verma, certified the state’s application as being complete despite the lack of local comment in the submission. Verma helped create Indiana’s current Medicaid program.

Having the state and federal comment periods overlap provided an “unprecedented opportunity to consider both sets of feedback before our final submission,” said James Gavin, spokesman for the Indiana Family and Social Services Administration.

Although the federal comment period was to end July 9, Gavin said Indiana asked the federal government to lift the deadline. Gavin said comments can be submitted “for the foreseeable future.”

Verma has said she is eager to give permission to states that want to experiment with imposing work requirements for able-bodied Medicaid recipients, an idea the Obama administration had rejected.

“We have reviewed that internally, and we think it’s within the authority to be able to approve something like that, within the appropriate safeguards,” she told USA TODAY in May. “These are very consistent with what’s going on in SNAP (the food stamp program) and our other welfare programs, and they’ve been very successful.”

Other states pursuing permission for work requirements include Kentucky, Arizona, Arkansas, Wisconsin and Maine.

Health groups and advocates for the poor — including the National Center for Law and Economic Justice and the American Lung Association — dispute Verma’s contention that the Centers Medicare and Medicaid Service has the authority to grant such requests.

Courts have said states can’t add additional requirements for Medicaid eligibility that are not in law, a coalition of groups wrote in its comments on Indiana’s request. The law would change under the GOP health care bills pending in Congress, but the legislation’s future is uncertain.

“Most people on Medicaid who can work, do so,” the coalition wrote, “and for people who face major obstacles to employment, harsh requirements won’t help them overcome them.”

The state argued in the application submitted by Gov. Eric Holcomb that increasing participation in the state’s Gateway to Work program will encourage Medicaid recipients to be self-sufficient and help them transition to getting their insurance through an employer.  

“The state believes this will lead to improved overall health for members, as the correlation between employment and better physical and mental health has been documented, as well as a better-trained workforce,” officials told the federal government.

Indiana’s work requirement would be phased in for those enrolled in the Healthy Indiana Program, the state’s alternative Medicaid program. The requirement would not apply to some participants, including pregnant women, those being treated for substance abuse, “the medically frail” and those older than 60.

Groups representing people with mental illness, cancer and other diseases told the federal government in their comments that it’s not clear who would fall under the “medically frail” exception.

“For those cancer patients who are mid-treatment, a loss of health-care coverage — even for a month — could seriously jeopardize their chance of survival,” wrote Christopher Hansen, president of the American Cancer Society Cancer Action Network.

The state estimates about 30 percent of current recipients would have to comply. If they’re not already working at least 20 hours a week or going to school, recipients would be required to participate in the Gateway to Work program. That program was created for the Healthy Indiana Program to connect unemployed recipients with job openings and with work search and job training programs. But participation has been low.

Those who don’t comply would be suspended from receiving health care benefits until they meet their required hours for a month. The state estimates about one-fourth — or about 33,000 — of those referred to Gateway to Work will choose not to participate.

The National Health Law Program said this estimate doesn’t include thousands more who will lose coverage “due to the red tape required to verify their exemption or work activities.”

Planned Parenthood of Indiana and Kentucky argues women will be disproportionately hurt because women are more likely to be caregivers of parents, spouses and other family members — work that typically would not fulfill a work requirement.

Indiana Legal Services said the work requirement appears more likely to “trip up” Medicaid recipients and create excess paperwork rather than helping recipients find and maintain employment.

Saint Joseph Health System, which operates hospitals and other health care facilities in north central Indiana, also expressed concerns about how difficult the requirement will be to administer in an “already strained and limited resource system.” Existing challenges include adequate staffing in the local Medicaid office that has been “plagued by continuous turnover and insufficient training,” delayed application processing times, technology issues, and communication problems between the state’s Medicaid office and the private carriers which operate the Medicaid program.

Indiana estimates the requirement would cost $90 a month per enrollee to administer. The Center for Law and Social Policy says that would be both a shift of resources away from needed health care while still not being enough for anything “but an ineffective, low-touch job search program that primarily serves as an additional hoop for beneficiaries to jump through.”

“The state has little evidence for why the current Gateway to Work program would fare better if mandatory,” wrote Jon Laramore, executive director of Indiana Legal Services.

One of the few expressions of support for the work requirement came from an anonymous commenter who views it as fair to other Hoosiers.

“As an employee,” the person wrote, “I have to pay for part of my insurance coverage, so those who get it for `free’ should either be working, looking for work, or in school unless a disability keeps them from finding employment.”

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