On January 11, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a State Medicaid Director Letter providing new guidance for Section 1115 waiver proposals that would impose work requirements (referred to as community engagement) in Medicaid as a condition of eligibility. With a proposal already approved for the Commonwealth of Kentucky and at least nine additional states poised to quickly follow suit, this hasty, ill-informed decision will create new barriers to health care for people with disabilities and further entrench workplace prejudices and stereotypes.
In over 50 years of the Medicaid program, work requirements have never been permitted. Under federal law, CMS can only approve a state’s proposal to change their Medicaid program when it promotes the objectives of the program, which are to increase positive health outcomes and access to health care. Previous administrations have repeatedly refused work requirement proposals, asserting they would run contrary to these goals and thus be illegal. In an unprecedented move, the Trump Administration has reversed this policy and attempted to justify its decision by citing the success of Medicaid-funded programs that provide employment supports to Americans with disabilities.
DREDF strongly opposes both the Administration’s endorsement of work requirements and the outrageous justifications for them. First, to be clear: work requirements are the opposite of supported employment programs and we reject the comparison. Supported employment provides voluntary services to increase access to work, and the Medicaid Buy-In helps people with disabilities maintain Medicaid coverage as their income rises. In contrast, work requirements block access to essential Medicaid coverage if an individual is not working or cannot participate in a work program because it does not fit their needs. Comparing the two is incorrect and reflects a fundamental misunderstanding of what Medicaid was created to do.
Medicaid work requirements will harm many people with disabilities by decreasing access to health care and employment. Specifically:
- Despite the Administration’s rhetoric, people with disabilities will not necessarily be exempt from work requirements. While most proposals include some form of disability exemption, states must screen and decide who qualifies as “disabled” for purposes of the exemption. The details will vary by state but some people will inevitably fall outside the state’s definition—even if they have disabilities that limit them from working, such as episodic or mental health conditions.
- Even if an individual is exempt, work requirements will create red tape that will result in people losing coverage. Individuals will have to verify their qualifying disability, which may involve screening, medical documentation, or other paperwork that makes it more difficult to apply for and stay enrolled in Medicaid. Likewise, non-exempt individuals (including many people with disabilities) will need to document their employment hours. As we have repeatedly seen in other public benefit programs, such as the Supplemental Nutrition Assistance Program (“SNAP” more commonly known as “food stamps”), the administrative obstacles created by work requirements will cause large numbers of exempt individuals to lose their benefits.
- Medicaid work requirements will widen disparities in health and employment. Contrary to the Administration’s claims, mandatory employment will not improve health outcomes. In fact, the opposite is likely to occur – work requirements will disqualify many individuals from Medicaid coverage, which will worsen health outcomes and decrease access to the health services and supports that many people with disabilities rely on to maintain employment. Especially when compounded with the prejudices and stereotypes that continue to increase barriers to employment for people with disabilities and other historically marginalized groups, these policies will only serve to perpetuate a cycle of employment inequity.
To learn more about Medicaid work requirements and their projected impact on the disability community, see the following resources: