Medicaid Work Requirements: Bad Policy for All, Particularly Harmful to People With Addictions and People of Color
Time after time, the Trump administration talks about our country’s drug overdose crisis, yet its relentless attacks on health care simultaneously undermine access to life-saving treatment and services for people with substance use disorders. The most recent example: forcing Medicaid beneficiaries to work in order to maintain their health insurance coverage.
The Centers for Medicare & Medicaid Services (CMS) will now allow states to impose work requirements, and has provided instructions for how states should implement these unprecedented rules. The guidance is now reality in Kentucky — a state with one of the highest drug overdose death rates in the country — where CMS recently approved a Section 1115 demonstration waiver requiring Medicaid beneficiaries to work for 80 hours a month, or else face a suspension of their coverage. Advocacy groups are already voicing opposition; the National Health Law Program, the Kentucky Equal Justice Center and the Southern Poverty Law Center have jointly filed a law suit against the Department of Health and Human Services (HHS) and CMS to block this Kentucky requirement.
For years, states have used demonstration waivers to experiment with changes in Medicaid eligibility and coverage, but work requirements have never been approved. Historically, they have been considered contrary to Medicaid’s objective to provide health coverage. There are many issues with work requirements: They are administratively burdensome for both consumers and state offices, they are unnecessary in that most individuals receiving Medicaid coverage already work voluntarily, they are unlikely to promote employment or health, and they ultimately create barriers to health care instead of improving access. While work requirements are a bad idea across the board, they are especially problematic for people living with substance use disorders.
What the guidance says:
The work requirements apply to “non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability.” Medically frail individuals are exempt, and states can broadly define their criteria for what it means to be “medically frail.”
Individuals with substance use disorders do not meet CMS’s “disability” criteria and would therefore be subject to the work requirements. In an attempt to recognize the needs of people with addiction, CMS instructs states to make “reasonable modifications” for individuals with substance use disorders and opioid addiction. They can count the time spent in treatment toward the work requirement — for example, Kentucky’s approach — or exempt individuals receiving certain intensive treatment from the requirement altogether. These modifications, however, fall short of fixing the problems inherent in imposing work requirements.
- Work requirements create barriers to care at a time when people with substance use disorders already struggle to access treatment and recovery supports.
Only about 10 percent of individuals with a substance use disorder received specialty treatment in the previous year, according to recent data. The last thing individuals need is another obstacle between them and life-saving services. Whether it is through the job search itself, or cumbersome administrative processes to verify either requirement fulfillment or exemption status, work requirements can inhibit the ability to access continuous care. Throughout their recovery process, people need to keep their Medicaid coverage and remain connected to the health care system in order to get and stay healthy.
- The “reasonable modifications” are inadequate.
The guidance narrowly references “inpatient treatment or intensive outpatient treatment” in the exemption criteria. Although it is often hard to access, intensive medical treatment is only one component of an individual’s recovery process. Someone with a substance use disorder may be tapping other services, such as peer coaching and community based recovery programs. So far, it does not appear that CMS will include those activities in the exemption criteria, and states might not elect to include them anyway. In addition, the road to recovery for people with substance use disorders might involve multiple episodes of treatment, but according to the guidance, as soon as someone leaves treatment they would no longer qualify for the exemption. The work requirement therefore jeopardizes recovery for individuals who have completed treatment but may still need recovery supports.
- Society has historically criminalized addiction, particularly in communities of color, leaving many with criminal records.
Requiring individuals with substance use disorders to find employment before they can obtain Medicaid coverage is particularly problematic, as some have a criminal history that is directly associated with their untreated addiction. While our society is evolving to recognize addiction as a public health problem rather than a criminal one, there were still 1.5 million arrests in the “drug abuse violations” category nationwide in 2016. Many of these individuals face barriers to employment because of these criminal records, and formerly incarcerated individuals face even larger obstacles while they seek work during reentry. Taking into account the disproportionately punitive approaches to substance use in communities of color through the “War on Drugs,” as well as the discrimination people of color face in the job market, these work requirements will only worsen health disparities between white people and people of color.
It is discouraging that other states are following Kentucky’s lead to impose work requirements. Arkansas, Arizona, Indiana, Kansas, Maine, New Hampshire, Utah, Wisconsin and Mississippi have already submitted similar proposals. If approved, they will ultimately jeopardize lives. We urge policymakers to consider the true harms of Medicaid work requirements, particularly for people with substance use disorders, and refrain from implementing them at all.