When the 119th Congress passed the Congress One Big Beautiful Bill Act (OBBBA), it made significant changes to state Medicaid programs, but these changes are not made in isolation. State must also meet existing obligations, including the obligation to ensure equal access to programs and services for people with disabilities. Thirty-five years ago Congress passed the Americans with Disabilities Act (ADA) to ensure that people with disabilities are not precluded from fully participating from all aspects of society because of “the failure to remove societal and institutional barriers.” In passing the OBBBA, Congress created new institutional barriers that will prevent disabled people from receiving the Medicaid services for which they are eligible. How a state meets its ADA obligations in implementing these changes will impact the amount of harm OBBBA inflicts on their residents with disabilities. In the process, states must remember that the ADA imposes an affirmative obligation on public entities to make their programs and services accessible, not simply respond to requests for accommodations or assistance.
OBBBA adds several harmful administrative barriers to the Medicaid program. One of the biggest generators of administrative barriers for disabled Medicaid enrollees are the “community engagement requirements” or work requirements. Although OBBBA includes exemptions for some disability-related populations and targets the work requirement at the “expansion population,” the carve outs will not encompass all those for whom their disability prevents them from meeting the work requirements. In addition, disability will also affect the capacity of people to meet the significant administrative burdens of showing that they are either meeting the requirements or should be exempt. OBBBA also requires this population to be renewed at least once every six months, subjecting people to the burdens of renewal and associated risk of termination more frequently. These, along with other changes, will make it much more difficult for people, especially people with disabilities, to enroll and stay enrolled in the program, even when they are meeting all the eligibility requirements.
Administrative Burdens Stymie Medicaid Access for Disabled Enrollees
Enrolling and staying in Medicaid is not an easy for many people. As Alice Wong described it, “The administrative burden, access barriers, and emotional toll it takes to jump through these hoops for survival is cruel and counterproductive.” And that was before the OBBBA.
For a lucky percentage of the population, Medicaid eligibility can be determined based on information available, such as through verifying information through data sources. However, this varies by state and often does not work for disability-related eligibility issues. The “unwinding” of Medicaid after the COVID-19 federal public health emergency ended revealed a dizzying array of issues with state eligibility systems and processes, many of which impacted people with disabilities in particular. Throughout the unwinding, Medicaid-eligible individuals with disabilities lost their access to health coverage because of system errors, confusing paperwork requirements, and a lack of assistance that would allow them equal access to the Medicaid renewal process. And this occurred with over 400 federally authorized, time-limited flexibilities to help people stay enrolled, which were not made permanent in most states. Although the unwinding likely revealed existing issues, the pressure on the systems exacerbated problems, especially the lack of available assistance, which in turn multiplied the harms. The OBBBA changes are expected to do the same, although potentially more so due to the degree of change, the timing, and the concurrent decrease in resources to state Medicaid programs.
States Must Meet Their ADA Obligations in Implementing OBBBA
The ADA is supposed to ameliorate administrative burdens by either eliminating burdens where possible or providing reasonable accommodations. In implementing OBBBA, states are obligated to evaluate how those changes affect equal access to the Medicaid program. How well they do so, including for all populations of people with disabilities, will significantly affect the harms of OBBBA.
The OBBBA requires states to make significant changes to eligibility systems and processes in a relatively short period of time. Evidence about work requirements shows that exemption processes do not work well, administrative barriers are significant, and people with disabilities will lose access to their Medicaid coverage. However, there are ways that states can set up their systems and processes to better identify when a person should meet an exemption and to do so on an ongoing basis with minimal administrative burden so the person does not lose coverage. States should also evaluate their processes and procedures to ensure that communications are to all enrollees, factoring in disability, language access, etc., and that the mechanisms to respond to communications, such as to submit information, are fully accessible to all Medicaid enrollees. Critically, assistance must be readily available for those who need it and that assistance must be accessible.
Many of the accessibility problems identified during the unwinding were preventable through better systems, processes, policies, and monitoring. In implementing the OBBBA changes, states need to think about equal access throughout the process—from application to renewal, and through termination and appeals. States should consider more robust testing of eligibility systems and user portals, monitoring protocols to identify and correct access problems, testing and monitoring of notices, improved policies and training for frontline staff that clearly address access issues, and clear accommodation policies that would address the full array of disabilities of the Medicaid population. For example, frontline staff at call centers or county offices sometimes only have accommodation policies that address certain disabilities, like communication needs. Therefore, when a disabled person has other accessibility needs, they frequently cannot navigate the limited available accommodations to figure out how to access help or receive the accommodation they need. Too often, states are relying on resolving an access complaint when it arises, rather than meeting their affirmative obligation to design a system that considers the needs of people with disabilities and how they will interact with that system and processes. Much like a state has to consider access needs when building a structure, they need to consider access needs when building and changing their eligibility processes.
Conclusion
Through the OBBBA, the 119th Congress has required repetitive, burdensome paperwork processes that will take away health care for millions, even when they are already working or should be excluded from the requirements. For many it will be the administrative burdens that take away their care, not their actual eligibility. People with disabilities will especially get caught up in administrative red tape. States must meet their ADA obligations and thus carefully consider how to set up policies and processes that will reliably ensure those who are eligible, get and retain Medicaid. For 35 years the ADA has existed to protect people with disabilities; it is needed now more than ever.
