Health care advocates celebrated when a federal judge recently blocked Medicaid waiver projects in Kentucky and Arkansas that condition Medicaid coverage on mandatory work requirements and other cuts to coverage. The Trump administration approved (and encouraged) states to impose such requirements in a backdoor effort to undermine Medicaid and limit its coverage. The decision in Stewart v. Azar marked the second time the court vacated HHS’s approval of Kentucky’s Medicaid waiver. While the decisions apply directly to Kentucky and Arkansas, their reasoning sends a strong message to states considering similar projects.
Medicaid is a health care coverage lifeline for tens of millions of individuals and families with low incomes, including 25 million women. Women comprise the majority of adults covered by Medicaid and include women of color, LGBTQ women, women with disabilities, and single mothers. When states like Kentucky and Arkansas impose mandatory work requirements, they make it more difficult for women and their families to keep their coverage.
The National Health Law Program argues in these cases that the HHS secretary is acting illegally when he conditions Medicaid coverage on work requirements. Work requirements are unnecessary, burdensome, and harmful to women and their families. Most women on Medicaid already have jobs, and among mothers, the percentage of working women on Medicaid is even higher. Yet women are also more likely to have low-paying jobs that do not come with health insurance coverage, particularly women of color, along with unpredictable work hours and unfair scheduling practices resulting in income variations. With no federal workplace protections and a patchwork of states prohibiting employment discrimination against LGBTQ individuals, many lesbian, bisexual, transgender and queer women face discrimination and harassment at the workplace, making it difficult for them to find and maintain employment. Moreover, many women are employed in informal job settings, such as domestic work, where there are no timesheets, paystubs, or other forms of documentation to verify their employment status and there is no health insurance coverage.
Fluctuations in income is a concern for Shawna McComas, one of the plaintiffs in the case challenging the re-approval of Kentucky’s Medicaid waiver. Shawna is a mother of four children ranging (ages 5-17) and works in housekeeping at the University of Kentucky Hospital where her hours and income can vary weekly. After Kentucky imposed work requirements on Medicaid, beneficiaries like Shawna worry that they will be locked out of Medicaid if they fails to timely file required forms to report changes in income or amount of hours worked. Treda Robinson, a plaintiff in the Arkansas case, has similar concerns. Her work hours fluctuate according to the volume of work available. She only knows how much work is available one day before the work is assigned.
Some women enrolled in the Medicaid program cannot seek work outside of the home because they must take care of family members. Thirty percent of adults enrolled in the Medicaid program reported that they did not work because they had caretaking responsibilities. Women in particular are more likely to have caregiver responsibilities for dependent children, parents, and family members with disabilities. For example, Robin Ritter, another Kentucky plaintiff, is the primary caretaker for her teenage daughter, who has neurological, physical, and learning disabilities, and of her husband, who has myriad medical conditions that restrict or slow his mobility. Women like Robin are at risk of being terminated from Medicaid for failure to meet the work requirement because they have no way to prove they are a caretaker.
In states that have not expanded their Medicaid programs, the people who could be most affected are mothers with very low incomes. Mississippi is a non-expansion state pursuing federal approval for a work requirement that would affect extremely low-income parents and caretaker relatives with incomes below 27 percent of the poverty line insured through Medicaid, one of the most restrictive eligibility limits in the country. Thousands of mothers, particularly black mothers, young parents, and/or parents living in small towns or rural areas, are estimated to lose their Medicaid coverage. Loss of parental coverage has a harmful impact on children too; research has shown that children with uninsured parents are less likely to receive health care. Loss of coverage may also increase the health disparities these individuals face, particularly black women, and expose them to additional stress, which in turn, fosters negative health outcomes.
While the approvals include exemptions for certain populations, such as pregnant women, primary caretakers of dependents or people with disabilities, and students, the exemptions are unworkable in practice. In Arkansas, more than 18,000 people have been yanked from Medicaid, including women like Elizabeth Cloinger, a home health aide who works seven days a week. Elizabeth was told she was exempt from the state’s work requirement because of her caretaking responsibilities for her 20-year-old daughter who was injured in a car accident and her 3-year old granddaughter. The information she received conflicted with letters from the state telling her that she needed to verify her income and create an online account. Her coverage was terminated because she didn’t realize the program required an email account, and she doesn’t have a computer. Elizabeth has not seen a doctor in months, despite some health conditions that have made it difficult for her to stand for long periods of time.
In short, work requirements affect everyone, not just people without jobs. Working women and women who are exempt from the requirement will be subject to confusing administrative rules and burdensome documentation requirements to prove their status. As Elizabeth’s story shows, even when she tried to cut through the red tape to comply with Arkansas’ exemption, she was cut from coverage. Other women may meet the same fate. People need health coverage to be able to work, not the other way around.
At the National Health Law Program, we believe waiver projects that reduce access to Medicaid coverage are illegal. To learn more about our policy work and litigation efforts concerning harmful Medicaid waiver projects, visit our website.