WASHINGTON -- The Centers for Medicare & Medicaid Services (CMS) for states wishing to implement work requirements for Medicaid recipients, declaring that "helping Americans at or near the poverty line improve their lives ... should be a cause that unites us all."
CMS Administrator Seema Verma made the statement during a conference call with reporters to discuss the guidance. Verma noted that 10 states have already applied for so-called 1115 waivers that would allow them to implement work requirements: Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah, and Wisconsin. The requirements would mandate that people in the affected states must be working, enrolled in school or job training, volunteering, or providing care for a family member -- activities referred to as "community engagement" -- in order to remain eligible for Medicaid.
The guidance is focused on able-bodied adults and "doesn't impact seniors, pregnant women, children, or those with disabilities," she said.
It also includes a specific section on individuals with substance use disorders, Brian Neale, director of the Center for Medicaid and CHIP Services, said on the conference call. For example, the guidance suggests that states could "count time spent in treatment toward [the work] requirement, or exempt a person going through inpatient or outpatient treatment from the requirement altogether." And it includes a definition of "medically frail" and says that states must exempt any individual with an acute medical condition -- as validated by a physician -- from complying with the requirement, he added.
Overall, the guidance is being offered "to strengthen the Medicaid program to better serve our beneficiaries," Verma said. "A strong Medicaid program ... does more than just provide [beneficiaries] a card."
Studies have shown that productive work and community engagement "may improve health outcomes," she said. "That points to the fact that Medicaid can and must do more."
States may also use the waiver to line up their Medicaid work requirements with those already in existence for their Supplemental Nutrition Assistance Program (SNAP) -- otherwise known as food stamps -- and Temporary Assistance for Needy Families (TANF) programs, Neale explained, adding that "the policy we put together will also include similar limitations and exclusions" as the ones found in those programs.
"States are encouraged to create consistent program rules to minimize potential confusion" for beneficiaries who are also enrolled in SNAP or TANF, although the 1115 waiver also could go beyond those programs' requirements in terms of what is considered acceptable community engagement for eligibility purposes, he told MedPage Today.
Asked whether it would be a good thing if the waivers resulted in fewer people being on the Medicaid rolls, Verma responded that "this policy is about helping people achieve the American dream. As I talk to Medicaid recipients, they want to get off public assistance; they want to have a better life ... We're giving them the skills and tools they need to have a better life. People moving off Medicaid is a good outcome; we hope it means they don't need the program any more."
But several consumer and medical organizations panned CMS's announcement. "Medicaid was designed as a healthcare program, to provide vulnerable members of our society with access to care they badly need," Jack Ende, MD, president of the American College of Physicians, said in a statement. "Work requirements impose an additional, unnecessary barrier to allowing patients access to vital health care services for people who need access and coverage the most."
"A recent analysis by the Kaiser Family Foundation shows that while 80% of Medicaid enrollees are in working families and a majority are working themselves, among the adult Medicaid enrollees who were not working, most report major impediments to their ability to work," said Ende. "The analysis noted that, 'More than one-third of those not working reported that illness or disability was the primary reason for not working... nearly nine in ten (88%) non-SSI Medicaid adults who report not working due to illness or disability has a functional limitation, and more than two-thirds (67%) have two or more chronic conditions such as arthritis or asthma.'"
"Medicaid is a critical piece of our country's healthcare system," he concluded. "We need to work together to find ways to improve the program, instead of restrict it, so that it better provides health care coverage to those who need it."
Public Citizen agreed, calling the idea of work requirements "cruel, stupid and illegal."
"It is cruel because it not only denies the basic truth that healthcare is a right, it explicitly conditions access to healthcare on wealth. The work requirement will deny care to untold numbers of Americans," Public Citizen President Robert Weissman said in a statement.
"It is stupid because it will actually prevent people from working – with health needs unattended, many low-income people will be unable to seek work. Even worse, it will undermine broad public health priorities" such as the opioid epidemic, he continued. And "it is illegal because it contravenes Medicaid's purpose of providing medical assistance to low-income and vulnerable people."
"Seema Verma has condescendingly talked about combating the 'soft bigotry' of low expectations for Medicaid recipients. What she is in fact doing is promoting the hard bigotry of animus against poor people – the hard and shameful bigotry of health care denial based on wealth," Weissman concluded.