By Rose Hoban
Members of the North Carolina Senate say they want able-bodied Medicaid recipients to work or do community service in exchange for receiving health care coverage from the state.
The request came in a bill that was filed on Thursday afternoon, which would provide exemptions for specific populations, such as children under 19 years old, people who are blind or who have a mental illness.
“We’re just saying, those of you who are already on Medicaid, or who will qualify for Medicaid, if you’re able-bodied, we’re going to have these requirements,” said Sen. Joyce Krawiec (R-Kernersville) who is one of the co-sponsors of the bill.
But there’s a big problem with the bill: To date, the federal government, which pays two-thirds of North Carolina’s Medicaid tab and which would have to give approval for the measure, has never approved such a work requirement for a traditional Medicaid program.
And the bill was filed just hours after a federal judge struck down similar work requirements applying to states that had expanded Medicaid, as allowed for under the Affordable Care Act. North Carolina has not expanded Medicaid.
“Nobody, not even this administration, has said yes to this,” said Sarah Somers, an attorney with the National Health Law Program, based in their Carrboro office. “So, good luck.”
After exceptions, who’s left?
There are already few so-called able-bodied people who are covered by North Carolina’s Medicaid program who are not in an excepted group.
Of the state’s 2.1 million Medicaid recipients, the vast majority, about 1.2 million, are children, who would be exempted from the work requirement.
The bill exempts many other groups that are included in the traditional Medicaid program, such as low-income seniors, around 150,000, and low-income pregnant women, a total of about 20,800 people.
Others who would be exempted from the work requirement would be people with mental health disabilities, physical disabilities or intellectual or developmental disabilities, all told, about 283,000 beneficiaries.
There is a large population of working age women, about 310,000 of them, who receive low-cost family planning services through Medicaid, at a total cost of about $10 per year. The bill also exempts people in this category of recipients.
All told, the bill contains 21 categories of individuals who would be exempted from the work requirement. The likeliest people who would be compelled to work are low-income parents of children older than one year old. Currently, parents of children under 18 years old are eligible for coverage if the family makes less than $8,928 a year for a family of four.
“We hope those that are on Medicaid now will continue to work and be able to find jobs,” Krawiec said. “We just want them to become self-sustaining, get in the workforce so that you can move up and be successful.”
Somers noted though that taking a job would put these parents into a double-bind.
“Let’s take a [welfare] recipient, that person qualifies with an extremely low income,” she posited. “If that person is required to work, even a minimal amount, and they actually succeed in doing that, they will no longer be eligible for Medicaid.”
But they would likely also not make enough to purchase insurance, Somers added.
When asked how many people she thought would be exempted, Krawiec said she didn’t know.
Federal ruling adds twist
Krawiec continued, “in the expansion population, the majority of them are able-bodied people.”
And that’s what the bill is likely about: Medicaid expansion.
The legislative building has been buzzing about the possibility of a Republican-sponsored bill from the House of Representatives likely to be introduced in the coming week.
The 2017 Carolina Cares bill would have extended insurance coverage to a half million low-income people who make too much to qualify for Medicaid but too little to receive subsidies to buy insurance on the marketplace created under the Affordable Care Act.
Several of the bill’s previous sponsors have remarked in recent weeks that they’re working on reintroducing their bill.
The original Carolina Cares bill included a work requirement, something that’s in place in about a half dozen states. Approval for a work requirement is pending in seven others.
Thursday’s federal court ruling could throw many of those requirements into limbo. In it, District Judge James Boasberg rejected the work requirements imposed by Arkansas and Kentucky. Both states had mandated that beneficiaries register that they were working at least 20 hours per week each month or, they would be dropped from the rolls.
In his ruling, Boasberg noted that in Arkansas, “In October, for example, only 12.3% (1687 out of 13653) of persons not exempt from the requirements reported any kind of qualifying activity.” He noted that since the work requirement went into effect in 2017, more than 16,900 beneficiaries had lost their coverage and he criticized the state for creating work requirements that were “both arbitrary and capricious.”
In the introduction to his decision, Boasberg cited the example of a man who did not realize he needed to report his employment through an online portal each month, thus causing him to lose his benefits.
Boasberg also criticized Health and Human Services Sec. Alex Azar for approving the work requirements, ruling that Azar “failed to consider adequately” the impact of the work requirements.
“Indeed, [Azar] neither offered his own estimates of coverage loss nor grappled with comments in the administrative record projecting that the Amendments would lead a substantial number of Arkansas residents to be disenrolled from Medicaid,” Boasberg wrote.
When asked how North Carolina Medicaid recipients were to record how they were fulfilling their work requirement, Krawiec said that would be up to the state Department of Health and Human Services.
She also noted that North Carolina has imposed work requirements on people who receive Supplemental Nutrition Assistance Program benefits (commonly known as food stamps) and who receive welfare benefits.
“The fact that they exist, in SNAP and TANF (Temporary Assistance for Needy Families, the welfare program) is because those statutes allow it,” Somers countered. “You can’t include work requirements in Medicaid. The statute doesn’t allow it. It’s not consistent with the objectives of the program.”
This was a large part of Boasberg’s argument: that if Congress wants Medicaid beneficiaries to work, they need to put that into the statute.
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