A federal judge in Washington, D.C., has given Gov. Mike DeWine and his fellow Republicans in the legislature a chance to think again. On Wednesday, Judge James Boasberg blocked the Medicaid work requirements approved by the Trump White House for Arkansas and Kentucky. He did so by holding close to the law, or the core purpose of Medicaid — to extend health coverage to the poor and disadvantaged.
In twin rulings, the judge described the approval by the Department of Health and Human Services as “arbitrary and capricious” in its failure to consider adequately the prospects for recipients losing coverage. Arkansas has provided proof. Since implementing its work requirement, the state has seen nearly 20,000 recipients fall out of the program.
Kentucky projects 95,000 losing coverage during the first five years. Might the recipients land private insurance, perhaps through a new job? The judge noted that federal officials “cited no research or evidence that this would happen.”
On March 15, Ohio won federal approval of its application for a waiver allowing a work requirement for those covered through the Medicaid expansion. The waiver doesn’t allow states to duck somehow compliance with the law. It is about experimenting to find new and better ways to achieve the program’s objectives.
So there’s a legal problem, as the judge stressed, when recipients lose coverage without having an alternative.
That is something for the governor and lawmakers to weigh as they move toward implementation. The state has crafted exceptions, for those age 50 and older, for caregivers, those with chronic illnesses or disabilities. Of the roughly 700,000 covered by the expansion, the state projects 18,000 would be vulnerable to losing coverage, though the Arkansas experience suggests it likely would be far more, even exceeding 100,000.
Recall the state establishing a work requirement for food assistance. The estimate was that 134,000 people would lose eligibility. The actual number was close to 400,000.
The idea behind the work requirement is seeing the able-bodied find a path to employment. That sounds reasonable. Yet research indicates having health coverage is the real boon to finding employment and keeping a job.
Recipients are healthier. The state’s independent assessment of the expansion found that coverage promoted work. The Center for Community Solutions points to studies showing the expansion serves as an incentive to pursue economic opportunities. During its five decades, Medicaid has proved a leading factor in advancing economic mobility for those in poverty.
The Cleveland-based think tank adds that the Medicaid expansion fits neatly into the larger economic landscape of the state. Ohio has benefited from an expanding health care industry, with the expansion adding nearly $6 billion a year in economic activity. Why, then, take steps that would shrink coverage?
To generate savings?
That is another argument for the work requirement. Put aside the problem that the reduced costs would result from taking away coverage, or running counter to program’s mandate. This pursuit of savings faces complications. For instance, the work requirement must be managed, involving additions to government offices as caseworkers track and evaluate recipients who must verify they hold jobs or otherwise are involved in work-related activities.
The Center for Community Solutions looked at the likely operating expense for Cuyahoga County. It estimates $378 million for the five-year waiver.
This is where many recipients would be most vulnerable to losing Medicaid coverage — failing to comply with the paperwork. It isn’t just a matter of falling short in their reporting. Many hold jobs in which the hours can be unreliable, one month meeting the required 80 hours, the next missing the mark, through no fault of their own.
They may lose coverage. It wouldn’t be because they aren’t working.
Without coverage, where would they go for care? No doubt, many would end up in more costly emergency departments. Hospitals would contend with increases in uncompensated care, down 50 percent since the expansion. The Center for Community Solutions cites state estimates that the overall per-recipient cost of Medicaid would increase as a result of the waiver. It would do so though state law calls for changes to “limit the growth” in the per-recipient cost.
So there is much for the governor and state lawmakers to rethink. Their Medicaid work requirement appears to have a problem with the law.
Douglas is the Beacon Journal/Ohio.com editorial page editor. He can be reached at firstname.lastname@example.org.