Medicaid Malpractice

In September, I wrote about a proposed waiver to Kentucky’s Medicaid program, which would foist work requirements on recipients (among other patronizing indignities like premium payments and “health incentives”) and would devastate Kentucky’s large newly insured population. Those work requirements directly conflicted with the federal Section 1115 waiver guidelines, which govern what’s allowable in Medicaid waiver requests.

This week, at a National Association of Medicaid Directors conference, Seema Verma, head of the federal Centers for Medicare and Medicaid Services, indicated that states could request waivers that would permit officials to impose work requirements as a condition of receiving Medicaid. Which means, according to Kentucky’s Medicaid Director Stephen Miller, the state’s waiver request will be approved “soon.”

Verma defended the changes this way: “Believing that community engagement requirements do not support the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” she said.

The “soft bigotry of low expectations”? This phrase brings two thoughts to mind.

First, what about the hard bigotry of requiring people to prove their worth to receive health care? That’s what Medicaid “community engagement requirements” (read: work and volunteer requirements) represent. These requirements would force the poor and low-income people who would be subject to these rules (and most of whom are already working) to prove that they are worthy of assistance—in this case, worthy of having good health.

Such requirements often include difficult reporting requirements like documenting each hour of work, and limited flexibility if family or other emergencies arise. They are based on the flawed assumption that people in poverty are lazy—a stereotype that has been disproven again and again.

My low expectations have nothing to do with poor people who receive Medicaid, and everything to do with Republicans who make false claims about how “hard work” will improve people’s lives, based on inaccurate ideas of who is poor and why.

I have low expectations that unemployed people who receive Medicaid will be able to find good work—not because they aren’t motivated to find work, but because the abysmal unemployment that plagues many areas in Kentucky and other states will be ignored by Republicans.

The consequences (and causes) of poverty don’t help either, like limited formal education, lack of employable skills, and lack of access to transportation. And since the Trump administration ended rules that would have made it easier for people on welfare to participate in job training, I also have low expectations that Republicans will facilitate participation in such programs.

Plus, even though most people on Medicaid work, many of those jobs are in retail, food service, and construction—sectors that often have variable and inconsistent payroll hours. It’s challenging to meet arduous reporting requirements, like the 20 hours of work per week requirement proposed in Kentucky, if one week you’re scheduled for 25 hours but the next you get 10. And Kentucky nonprofits have already indicated they don’t have the capacity to create new volunteer positions for anyone who wants one.

In short, I have low expectations that any policy that is based on false assumptions about the poor will in any way help them in escaping poverty. Instead, these policies, which reinforce stereotypes of the lazy poor person, are designed simply to push people off of assistance programs in order to limit welfare, decrease the size of government, and save money.

Remember that under past administrations, work requirements were at odds with Medicaid waiver guidelines. So what did the Trump Medicaid officials do? They simply rewrote the rules. “Seemingly, they did that so they could push through Kentucky’s waivers and other waivers after that,” says Dustin Pugel, research and policy associate at the Kentucky Center for Economic Policy.

In her conference remarks, Verma said, “The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working-age, able-bodied adults does not make sense.” The problem with this statement is that poor working-age, able-bodied adults are some of our most vulnerable citizens. But in Kentucky, Medicaid expansion allowed this population to finally access health care. New Medicaid recipients began accessing preventative services, and were more likely to seek care for chronic conditions like diabetes. The state got healthier.

The Trump administration is putting those gains into jeopardy—as it will for any Medicaid expansion state that is granted a waiver. In Kentucky, “the changes will result in at least 95,000 fewer people covered, primarily because they can’t keep up with the requirements,” says Pugel. Medicaid provides health care for low-income people. The Trump administration twists this objective into nothing more than shaming the poor.