States try a gentler approach to getting Medicaid enrollees to work

Reviewed by James Ives, M.Psych. (Editor)Oct 29 2019

Under pressure from the Republican-controlled Pennsylvania legislature to require Medicaid recipients to work as a condition for coverage, state health officials have devised a gentler approach to getting beneficiaries into jobs.

Starting early next year, the Pennsylvania Medicaid agency under Democratic Gov. Tom Wolf will ask people when they enroll if they want job training assistance. It will then require its private Medicaid managed-care organizations to connect those who want help to local employment specialists and follow up to make sure they got it.

Teresa Miller, the state human services secretary, predicts the strategy will get better results than strict work requirements. The Trump administration has approved requiring work in nine states, with requests from nine others pending. Arkansas is the only state to implement the requirements, and more than 18,000 enrollees there lost coverage from June 2018 to March 2019 — with little sign many found jobs.

Since then, a federal judge struck down the work requirements in Arkansas, Kentucky and New Hampshire. The Trump administration and the states are appealing the decision.

"I worry that, with its reporting rules, work requirements result in fewer people covered by Medicaid, and that is not our goal," Miller said. "Our goal is to try to get people out of poverty. If you take access to health care away for people not working, I'm not sure how that helps people get a job."

A handful of states are offering alternatives to get more enrollees into jobs to lift them out of poverty and off Medicaid, the federal-state health program for low-income residents.

In Montana, about 32,000 of the 95,000 adult enrollees who gained coverage when the state expanded Medicaid in 2016 have received employment services from the state, including 4,200 who received one-on-one employment training services.

In August, Louisiana began a pilot program to train Medicaid enrollees for jobs such as a nursing assistant, commercial driver and forklift operator. It expects 50 people to complete the training this year at a community college.

More states are expected to follow. "While currently only a small number of states are starting to more directly connect Medicaid with the workforce training systems, this is a trend that will soon expand to many more states," said Steve Bella, a Bend, Ore., health and workplace consultant.

Bobbi Stammers, 37, enrolled in Montana's Medicaid in 2017 and said the state's job training assistance helped her get a nursing degree this year. The program paid thousands of dollars for her education expenses and supplies, including for textbooks and lab fees, and even covered the cost of fixing her car.

Two months after getting her degree, Stammers has a job with full benefits as a registered nurse, which means her family no longer needs Medicaid.

"I am so thankful I did this program; it really helped me get through school," said Stammers, of Charlo, Mont.

She used student loans to pay tuition, but with her husband working as a self-employed truck driver, Stammers said, additional expenses were burdensome. "This program eased the way for sure," Stammers said.

Conservatives nationwide have pushed for work requirements since Medicaid expanded dramatically under the Affordable Care Act. That law allows states to use federal funds to provide coverage to all adults with incomes below 138% of the federal poverty level, or $17,230 for an individual. Before that, many states limited adult enrollment to pregnant women, parents and people with extremely low incomes.

Despite the focus on getting Medicaid enrollees into jobs, studies show most people on Medicaid already work, and many of the rest have some disability, go to school or are caring for a family member.

Connecting people with job training is part of a broader effort by some states to improve Medicaid enrollees' health beyond paying for doctor and hospital care, said Hannah Katch, a senior policy analyst with the Center on Budget and Policy Priorities, a left-leaning advocacy group. She said states are looking at other social determinants of health, including housing and food services.

Montana's effort has been successful, Katch said, because it surveys people about their job status and training needs and then uses caseworkers to get them into career programs. About 60% of Montana Medicaid enrollees surveyed said they are employed, and 70% expressed interest in learning about opportunities in part-time or full-time jobs. The top three barriers to employment were poor finances, a criminal conviction and lack of transportation, according to the surveys.

A study by the state found its job training program helped lead to a 6% increase in Medicaid expansion-eligible adults joining the workforce from 2016 to 2018.

Despite the success of Montana's voluntary program, conservative lawmakers earlier this year pushed through legislation requiring that the state apply to the Trump administration for a waiver to mandate that Medicaid enrollees find jobs to keep their coverage, as well as pay monthly premiums based on how long they are on the program.

Health policy experts in Montana fear the work requirement will unfairly punish people who fail to report their employment status.

"We are worried those who are working are going to be subject to some pretty strict reporting requirements in order to maintain their health coverage," said Heather O'Loughlin, co-director of research and development at the Montana Budget & Policy Center. "We know there will be a loss of coverage, leaving people in a worse position to take care of themselves."

Pennsylvania's effort to assess enrollees about their job training interest comes after the governor has twice vetoed legislation to enact work requirements. The legislature will take up the same bill this year.

Sen. David Argall, a Republican co-sponsor of the measure, said the state's effort on job training doesn't go far enough.

"What they are suggesting is a tiny step in the right direction, but we need to do so much more," Argall said.

"Everyone tells me we have tens of thousands of able-bodied Pennsylvania residents receiving Medicaid but not working, and we need to be more aggressive in encouraging them to reenter the workforce," he said. "We are not asking Great-Grandma to work in a coal mine. We are talking about guys in their 20s who need an extra push."