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Red States Push Job Requirements for Medicaid Recipients

By Marissa Evans, CQ Roll Call

March 18, 2016 -- The handful of red-state governors and lawmakers who have been willing to expand Medicaid under the Affordable Care Act have tried to put their own spin on the program—and one of their favorite ideas has been pushing recipients to find jobs.

The federal Centers for Medicaid and Medicare Services (CMS), which holds that Medicaid is for health insurance, not employment, has so far not granted waivers that would allow states to require Medicaid beneficiaries to enroll in job-search and training programs.

CMS is expected to rule soon on such a waiver sought by Arkansas Gov. Asa Hutchinson, who wants to require adult Medicaid recipients to join a mandatory work referral program. Without that requirement, the Republican governor argues, he won’t be able to persuade Republican lawmakers in his state to approve his plan to continue its Medicaid expansion beyond the end of 2016. Arizona is seeking a similar waiver.

Forty percent of Arkansas residents who went onto the rolls under expansion—enacted in 2014 by Hutchinson’s Democratic predecessor, Mike Beebe—are unemployed, live in places where there are few jobs available, and lack skills to land a job. Hutchinson said at a news briefing last month that the new requirement would help beneficiaries "move up the economic ladder."

"We’re still trying to hone down and identify how we can move these people into work or work training opportunities and move them up the employment ladder so that ultimately they move off the Medicaid expansion," Hutchinson said.

Frustrated by CMS’s refusal to grant such waivers, at least three states—Indiana, Montana, and New Hampshire—have connected voluntary work referral programs to their respective Medicaid expansion plans, advertising them to new enrollees as a perk for signing up. In Montana and New Hampshire, Democratic governors are working with Republican-controlled legislatures, while Republicans hold both houses and the governor’s office in Indiana.

Under the 2010 health care law, states could expand Medicaid eligibility to individuals with incomes up to 138 percent of the poverty level starting in 2014. The cost is fully covered by the federal government until 2017, when states that expanded will have to start chipping in. By 2020, states will have to cover 10 percent of the cost. So far, 30 states and the District of Columbia have implemented expansion.

Since May, 153 of the 500 people who participated in the Indiana program’s orientation have found jobs such as dishwashing and substitute teaching. Dave Smalley, program administrator for Gateway to Work in Indiana, says it’s focused on people who have no work experience when they enroll, and creates individual action plans that identify beneficiaries’ strengths and personal barriers.

"I would hope once we get them into entry level [jobs] that we continue to try working with these individuals ... to see what can we do to get them to the next level or get that raise or retain that employment," Smalley says.

Montana launched its HELP-Link program on Jan. 1, providing services such as résumé assistance and job matching for Medicaid recipients. The program does not yet have job-placement data for the 178 people who have completed the initial self-assessment.

Agency officials say some of the biggest barriers to employment for participants have included previous convictions, poor credit histories and lack of transportation. Participants in rural areas are also facing general lack of job or education opportunities in their community.

Annie Glover, director of public health and economic security initiatives for the Montana Department of Labor and Industry, says the agency is working with more community organizations to increase its outreach. It hasn’t been easy to get Medicaid enrollees to take advantage of the program, especially ones who are already working full-time but could potentially benefit from career advice and more training.

"It’s just not something we can communicate easily in a letter or a phone call," Glover says of the work program. "They associate Medicaid with health care so it takes a bit more explanation to talk to them about the added benefits of the program which they might not associate with health insurance."

A spokesman for the U.S. Department of Health and Human Services, Jonathan Gold, says that states are free to do work-referral programs as long as they don’t pay for them with Medicaid funds.

"Medicaid’s central objective is providing access to health care for low-income residents," Gold says. "That’s our central objective and anything outside of that, states are free to supplement in other ways."

Trish Riley, executive director for the National Academy of State Health Policy, says the federal Temporary Assistance for Needy Families and the Supplemental Nutrition Assistance Program have traditionally done welfare-to-work programs. She says states are trying to find new ways to support low-income people—and get them off Medicaid.

"There’s a concern about long-term unemployment among low-income people," Riley says. "Getting them healthy matters, and making sure they’re healthy enough to work and they get into programs to help them get into work matters."

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