For some lower-income Americans, Medicaid is their lifeline to health care. That includes “older nonelderly” adults from 50 to 64 — an age range when chronic health conditions and mobility issues are common. Other people use Medicaid benefits so they can serve as family caregivers.
On Jan. 11, the Centers for Medicare & Medicaid Services announced that states can apply for waivers to implement work requirements for people who receive Medicaid benefits. Some older Americans will be affected.
To date, waivers have been approved in three states and are pending approval in others. Age limits vary for who might have to fulfill work or “community engagement” requirements for up to 80 hours a month. In Kentucky, Medicaid recipients are exempt at 64. In Indiana, 60 is the cutoff age. In Arkansas, however, 50 is the cutoff.
As of early April, other states seeking to implement work requirements include Arizona, Kansas, Maine, Mississippi, New Hampshire, Utah and Wisconsin.
[See: 13 Ways to Stay Healthy in Tough Economic Times.]
Ronnie Maurice Stewart, 62, of Lexington, Kentucky, has always been a hard worker. If anything, his jobs became more physically demanding as he reached middle age and beyond.
Stewart’s early career as a social worker spanned two decades. However, he was laid off at the North Carolina agency where he’d been employed 10 years, along with other co-workers. He found short-term social-work employment but nothing permanent.
So Stewart moved on to Nashville. “Agencies in Tennessee did not want, it seems, to hire someone of my age,” he says. With professional jobs unavailable, he took whatever came his way, including construction labor and work that involved driving with a rental car company.
Stewart’s health is not the greatest. His health history involves myriad conditions. He takes prescription medication for diabetes and high blood pressure. Hip and knee arthritis, along with a pin placed in his knee following an injury, affect his mobility. Cataracts in both eyes reduced his vision to the point of being legally blind, and no longer fit for his rental company job.
But Stewart wanted — and needed — to keep working. He moved to Kentucky and obtained Medicaid coverage. Cataract surgery, covered by Medicaid, restored his vision. He could check in with his doctor every few months to monitor his health.
Stewart found work as a hospital technician on emergency and trauma units. Unfortunately, he realized that keeping up with the rapid ER pace was just too difficult.
At that point, Stewart decided to take his Social Security retirement. He qualified for 80 percent of the full benefit when he turned 62, in July 2017. He also re-enrolled in Medicaid.
Now, Stewart faces the possibility of either having to return to work — assuming someone will hire him for at least 20 weekly hours — or lose his health coverage.
[See: 11 Things Seniors Should Look for in a Health Provider.]
Beth Kuhn, commissioner of the Kentucky Department of Workforce Investment, notes that most people on Medicaid also receive Supplemental Nutrition Assistance Program benefits. (SNAP benefits are also known as food stamps.) For those 80 percent of Medicaid recipients, she says, work requirements don’t apply after age 49.
Community engagement is the prime focus of the new requirements, Kuhn says. That encompasses four facets: volunteering; training and education; work and caregiving of a family or community member in need.
“There are many folks who are excluded from the requirement,” Kuhn says. “A key group, when we talk about the impact on older adults, is people who are medically frail. The purpose of this is to improve health outcomes, not to do anything that would be detrimental to health outcomes.”
Medical frailty would be determined by an eligibility specialist. For now, however, it is unclear how chronic medical conditions affecting many beneficiaries — such as asthma, cancer, diabetes, heart disease, high cholesterol and hypertension — would be considered.
For overburdened caregivers, Kuhn says, “We’re working hard to be attentive to the realities people face in these situations.” Technology is being developed for people to self-assess and enter their community-engagement hours via their smartphones, with alternative access for those who don’t own one.
Kuhn says the requirements address areas in which Kentucky needs to improve: health outcomes like life expectancy, and educational attainment. Volunteering, taking courses to improve job qualifications and changing health behaviors could have a positive impact on social determinants of health, she says.
[See: 13 Ways Social Determinants Affect Health.]
The fact is, most people who can work already do, according to Sara Rosenbaum, a professor of health law and policy with the Milken Institute School of Public Health at the George Washington University.
Older adults who get caught up in the new work requirements could find it difficult to fulfill them, Rosenbaum says: “People who just don’t have skills; who got laid off; who did hard, intensive labor all their lives and now they just can’t do it anymore, or they can do a very limited amount.”
Providing documentation places another burden on already maxed-out caregivers, Rosenbaum says.
“A mandatory work rule is such a silly waste of resources [considering] how few people are actually sitting around not working,” says Rosenbaum, who deplores the “thoughtlessness” of the idea. “You can only understand it as a way to drive people off the program.”
[See: 14 Ways Caregivers Can Help Themselves.]
On Jan. 24, the Southern Poverty Law Center, National Health Law Program and Kentucky Equal Justice Center filed a federal class-action lawsuit on behalf of a group of Kentucky residents receiving Medicaid, challenging the legality of Kentucky’s plan. Stewart is the lead plaintiff of the 16 Kentuckians now represented in the lawsuit.
“It’s important to understand there are a lot of people like Mr. Stewart who’ve worked hard all their lives,” says Anne Marie Regan, a senior attorney with the Kentucky Equal Justice Center. “He’s obviously worked really hard at different jobs. It’s not like he’s been sitting around collecting public benefits when he hasn’t contributed to society.”
Until July, when work requirements go into effect, there’s no avenue to apply for an exemption. “The state is still in the planning stages for how medically frailty will be determined and what the process will be,” Regan says. “It’s possible Mr. Stewart might qualify, but that’s not at all clear right now.”
In early April, Rosenbaum and other prominent health scholars filed a friend of the court brief in support of the SPLC’s lawsuit. Another brief was jointly filed by groups including Justice in Aging, AARP, AARP Foundation, the National Academy of Elder Law Attorneys and the Disability Rights Education and Defense Fund.
“The brief we filed focused on elimination of pre-application coverage, elimination of non-emergency medical transportation and the imposition of lockout penalties for various transgressions,” says Eric Carlson, a directing attorney with Justice in Aging. “With no pre-application coverage, a person might be liable for thousands of dollars of health care costs just because her injury prevented her from filing the Medicaid application until the following month.”
Non-emergency medical transportation allows people to make it to their medical appointments when they have no alternative, but the waiver eliminates this benefit. The “lockout” penalizes persons for administrative mistakes by barring them from Medicaid coverage for up to six months.
The new work requirements are classified as a “Section 1115” Medicaid demonstration project. The purpose is to “demonstrate and evaluate state-specific policy approaches to better serving Medicaid populations,” according to Medicaid.gov.
“They’re experimental waivers that under the statute should be for the purposes of advancing the objectives of the Medicaid program,” Carlson says. “But it’s just hard to look at this and see them as good-faith experiments to improve the Medicaid program. In all these ways, you’re dialing back coverage, you’re eliminating services and you’re erecting roadblocks to Medicaid coverage.”
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How Medicaid Work Requirements Could Hurt Older Americans originally appeared on usnews.com
