MM Curator summary
[MM Curator Summary]: Lawmakers are working to get key changes to their expansion program, including ways to track costs of Medicaid expansion more precisely and work requirements.
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Rep. Hannah Kelly, R-Mountain Grove, left, Rep. Cody Smith, R-Carthage, Center, and House Republican Aid Ryan Nonnemaker talk during a debate over a Medicaid tax bill in the House chambers at the Missouri State Capitol Building in Jefferson City on Wednesday, June 30, 2021. The special session was called to pass the Medicaid tax bill, which has passed the Senate. Photo by Colter Peterson, firstname.lastname@example.org
By Grace Zokovitch St. Louis Post-Dispatch
At a budget committee hearing, Missouri House members asked questions to the bill’s sponsor, Republican Rep. Cody Smith. Democrats’ questions focused on the work requirement language, and wording that would allow the legislature to fund only portions of people in the Medicaid program.
JEFFERSON CITY — Missouri lawmakers are kicking around work requirements for Medicaid enrollment for the fifth year running.
This year’s push packages the work rules within a proposed constitutional amendment giving the Legislature legal authority to defund voter-approved Medicaid expansion, for which an estimated 275,000 residents are now eligible. That number includes nearly 127,000 low-income adults whose families include at least one full- or part-time worker.
The legislation, sponsored by House Budget Chairman Cody Smith, R-Carthage, would institute a requirement for Medicaid recipients to work or do qualified community engagement for 80 hours a month. If passed by lawmakers, the amendment would go on the November ballot for voters to decide.
These requirements could take the form of traditional employment or fall under the “community engagement” as outlined in the resolution — education, substance abuse treatment, community service, volunteer child care, and job search or readiness training.
“Having those requirements alongside a benefit package like Medicaid is helpful — it helps people enter the workforce, or provide community service, or further their education,” Smith said. “Those are all positive outcomes.”
The proposed work requirements would apply to applicants between ages 19 and 65 and allow for some exemptions.
Exemptions include people with disabilities or serious illnesses, certain caregivers, those with limited access to public transportation or education, and those suffering from traumatic or exceptional circumstances. The proposal allows the Department of Social Services to use discretion in determining a candidate’s eligibility for an exemption.
The House Budget Committee conducted a public hearing on the resolution Wednesday, which is further than past proposals have progressed in recent years.
While Missouri’s debate may be gathering momentum, similar work requirement programs around the country have been collectively hitting a wall.
In 2018, Centers for Medicare and Medicaid Services leadership under President Donald Trump’s administration sent a letter to states greenlighting potential work requirement programs, a reversal of former CMS policy. States could institute work requirements by passing the policy and applying for a federal CMS waiver.
The letter led to a wave of attempts to pass work requirements, but court rulings and then the COVID-19 pandemic stalled the states’ programs or applications. At the time President Joe Biden took office last year, none of the 17 states that had attempted work requirements had succeeded.
Biden’s administration halted further attempts at implementation, and CMS has indicated it will not approve new applications.
“I have noted that CMS has not looked favorably upon the requirements in recent past,” said Smith, adding that he felt charged to put forth “good public policy” for the state regardless.
“It would be unfortunate if CMS denied our ability to govern as we see fit in Missouri,” Smith said. “I’m hopeful that they would take the will of the people and a constitutional change as a signal that this is how we want our Medicaid program to work and that they would try to help accommodate that rather than oppose it.”
Effect on enrollment
Testimony at Wednesday’s budget committee hearing was split on the likely end result of the policy — an increase in employment or a decrease in health care.
Proponents argued the requirements built in a “path to independence.” Others countered that barriers to health care were more likely to drive people further from economic stability.
Most testimony opposed the legislation, with many fearing that new bureaucratic and administrative barriers would result in significant disenrollment, even with the exemptions.
Emily Kalmer, representing the American Cancer Society Cancer Action Network, cited the experience of Arkansas, the only state to fully implement a work policy. The program lasted nearly a year, she said, before a federal judge halted it in 2019. Kalmer said the requirements resulted in the about 18,000 people disenrolling from Medicaid in the first six months.
“In Arkansas, many individuals who met an exemption category were unaware that they were exempt, while others were unable to successfully navigate work requirement reporting and lost their Medicaid coverage,” said Kalmer.
Letters that CMS sent last year to inform states of the work rule reversal cited similar concerns.
A letter to South Carolina, for example, referenced a Kaiser Family Foundation study that found 77% to 83% of disenrollments would likely be caused by simple nonreporting, based on a nationwide model.
The CMS letter said that work requirements had “only modest and temporary effects on employment, failing to increase long-term employment or reduce poverty.”
Similarly, a 2020 Harvard study reviewing the effect of Arkansas’ Medicaid work requirements on employment found the policy had failed to boost employment.
Opponents noted the requirements leave large gaps in types of employment. People with temporary or seasonal work, gig jobs or those with unpredictable or irregular hours, and other nontraditional work have reportedly been unable to consistently meet requirements, as noted in the CMS letters.
Debate has also centered on the cost of the policy. Though lower Medicaid enrollment decreases the cost, running the work requirement program takes significant funding, critics say.
The administrative costs in five states with approved work requirement proposals, according to a 2019 Government Accountability Office report, ranged from $6 million to $270 million. These costs would be shared between states and the federal government. At the high end, Kentucky’s estimate included significant technology updates.
But Smith said he believes those costs in Missouri “would be minimal.”
“We do already, obviously do eligibility checks, and enrollment, verification, those types of things,” he said. “I’m hopeful that we could fold additional reporting requirements into the process already.”
The legislation is House Joint Resolution 117.