Complex mandate 

Oklahoma has a long road ahead of it before controversial Medicaid work requirements can be put into place.

click to enlarge Oklahoma Health Care Authority, led by chief executive officer Becky Pasternik-Ikard, has until Nov. 1 to prepare, approve and submit the state’s work requirement for able-bodied Medicaid recipients to the Centers for Medicare and Medicaid Services. - OKLAHOMA HEALTH CARE AUTHORITY / PROVIDED
  • Oklahoma Health Care Authority / provided
  • Oklahoma Health Care Authority, led by chief executive officer Becky Pasternik-Ikard, has until Nov. 1 to prepare, approve and submit the state’s work requirement for able-bodied Medicaid recipients to the Centers for Medicare and Medicaid Services.

In January, the federal Centers for Medicare & Medicaid Services (CMS), with encouragement from the White House, announced that it would allow states to mandate work requirements for able-bodied Medicaid recipients to receive benefits and released guidelines for how those mandates should look.

Four months later, Gov. Mary Fallin signed a bill that requires the state to seek such a waiver from CMS, joining several other states that have either already earned approval for a new work requirement or are seeking it.

Proponents of such a mandate argue that working provides physical and mental health benefits, while detractors say the requirements are discriminatory and might force people in need out of the low-income medical assistance program.

While Oklahoma’s desire to impose work requirements on capable Medicaid recipients is clear, the specific population of people the mandate will affect takes some figuring. Medicaid programs are intended to assist primarily those who are not able to work.

“The majority of our members are either pregnant or children or physically disabled,” said Oklahoma Health Care Authority (OHCA) spokesperson Jo Stainsby. “That’s not that category.”

Stainsby said the work requirement will primarily affect parents and caregivers of school-age children. The bill Fallin signed gives exemption to those younger than 19 or older than 50 and parents of children younger than 6, mirroring the work-requirement limits set on the Supplemental Nutrition Assistance Program (SNAP). There are some other exceptions listed in the bill, like the exemption of Native Americans, that depend on federal approval.

All of that narrows the field of Oklahoma Medicaid recipients who might face work requirements to around 8,000, according to OHCA estimates.

“That number is still going to change as we work out exactly what exemptions are going to be included in the waiver,” Stainsby said.

It is not yet known when the state’s work mandate will actually be put into effect. What will specifically qualify as work is not fully understood yet either. Most states that have had their mandates approved or have submitted applications to CMS require 80 hours of work (or a community service alternative in some cases) per month.

Carly Putnam, a policy director at the nonpartisan nonprofit think tank Oklahoma Policy Institute, warns that however the final mandate might look, its implementation could be problematic for a lot of low-income people already in tough situations.

“If we’re really, really lucky it will be a minor inconvenience,” Putnam said. “At worst, people could lose access to life-saving health care.”

Long process

OHCA chief executive officer Becky Pasternik-Ikard is required to seek federal waiver by Nov. 1 under the bill Fallin signed. But there is a lot of work to be done to get to that point, and there is no telling how long it will take CMS to review the state’s submission.

Stainsby, OHCA director of public information, said the first step is for the OHCA board of directors to prepare a recommendation for the work mandate, which will include tribal consultation and an opportunity for public comment.

Once the recommendation gains board approval, it will be sent to CMS. While there are set expectations for when OHCA gets that request to the federal agency, what will happen after that is not as clear.

“Where a little bit of the unknown comes in is how long it’s going to take CMS to view and act on the waiver submission,” Stainsby said.

Other states have already submitted their own waivers to CMS. Arkansas, Indiana, Kentucky and New Hampshire have had theirs approved, while Alaska, Arizona, Maine, Minnesota, Mississippi, Michigan, Ohio, Utah, Virginia and Wisconsin have formally submitted requests to CMS.

The backlog of states waiting for approval might mean Oklahoma has to wait in line.

“I expect that [CMS] will deal with them before they get to us,” Stainsby said.

Oklahoma likely has a long road ahead of it before any labor requirement could be put into place. Stainsby said work has only just begun.

“This is just the starting point,” she said. “The bill just passed and the executive order just came down in March, and that’s just kind of the springboard.”

Stainsby encouraged anyone with input on the mandate to be present for the board’s public comment hearing, which will be scheduled for sometime in July.

“We do plan to take into consideration anything that is submitted as comment,” she said.

Coverage gap

Putnam said it is important to remember that every state is approaching the work requirement a little differently. Some states have already been approved, but none of them look like Oklahoma.

“The Health Care Authority, I think, is very much trying to assemble this airplane while they’re flying it,” Putnam said.

Oklahoma’s past refusal of federal Medicaid expansion providing health care to low-income families through the Affordable Care Act presents another unknown in the work mandate.

Earlier this month, CMS administrator Seema Verma warned states without expanded Medicaid that work requirements would likely leave some without any coverage options.

As Medicaid recipients find jobs or increase their work hours to meet the 20-hour weekly requirement, some of them will make enough money to bump them out of the Medicaid threshold.

“It creates this catch-22 where they’re working to comply with the work requirement and then fall into the coverage crater with the 200,000-odd other low-income adults with no access to health care,” Putnam said.

All of the states that have had their work mandates approved by CMS so far are states with expanded Medicaid coverage.

Above any other issues with the mandate, Putnam said a work requirement is simply unneeded.

“There is no substantive reason for the state to be pursuing a work requirement,” she said. “No matter how many arguments you have for what should or shouldn’t be included as an exemption or should or shouldn’t count as a work activity, the fact remains that it feels like a fundamentally dishonest conversation.”

Setting roadblocks?

A federal lawsuit filed in January by a group of 14 Kentucky plaintiffs is being pressed against the U.S. Department of Health and Human Services over the state’s CMS-approved work requirement, arguing that the mandate goes against the intended nature of Medicaid services.

Justice in Aging is one of several organizations acting as a friend of the court in the case. Eric Carlson, directing attorney at the senior advocacy organization, said he does not believe the work mandates are about encouraging participation, advancing skills or supporting the mental health of Medicaid recipients.

“It’s a mechanism to limit or reduce enrollment,” he said. “It’s another roadblock for low-income people to face when they’re attempting to get Medicaid coverage. It reflects a certain hostility toward this population.”

Carlson said Justice for Aging has been and will continue to watch developments in the mandates other states are making. He said the advocacy group believes the courts should rule against CMS.

“It’s not advancing the objectives of the Medicaid program,” he said. “In fact, it’s doing the opposite.”

Putnam does not want to read malicious intent into state lawmakers’ push for these requirements, but she also thinks the mandate provides a solution for a problem that does not seem to exist.

“The problem is we know that most people who can work already work,” she said. “Most people are not choosing to live in deep poverty for the fun of it.”

If the intent of the mandate is backed by a desire to get people believed to be disconnected from employment back to work, Putnam said there are other ways to do that, like increased child care and elder care services, transportation options, and accessible and available treatment for mental health and substance abuse disorders. The work mandate, she said, gets these people no closer to any of these things.

“From what I’ve heard from legislators discussing this bill is that there is a genuine desire to help people,” she said. “But our concern is that in an effort to help people, we’re actually going to make their lives substantively worse.”  

Editor's note: This story has been updated to reflect that the current director of Oklahoma Health Care Authority is Becky Pasternik-Ikard. An earlier version of this story identified the director as Pasternik-Ikard's predecessor, Nico Gomez.
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