AHA Continues Speaking Against Alabama's Proposed Medicaid Work Requirements

As you may know, Alabama has asked the Trump administration to approve work requirements for Medicaid beneficiaries. The American Heart Association recently submitted comments against the proposed waiver during the federal comment period running September 21 - October 21, 2018.

If approved, Alabama's proposed waiver would require Medicaid beneficiaries to work or participate in "employment-related activities" for 35 hours a week or 20 hours a week for parents of children younger than six. Individuals will have 90 days to prove their compliance with the requirements or their health coverage will be terminated. "Employment-related activities" would include attending on the job training, job searching, attending school, volunteering, work activities, community service, or technical training. According to Medicaid.Alabama.Gov, the following individuals would be exempt from the employment requirements: 

• Anyone who has a disability, is medically frail, or has a medical condition that would prevent them from complying with the work requirement, as validated by a medical professional, including anyone receiving Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), or Medicare.
• Anyone who is pregnant or receiving post-partum care
• Anyone age 60 or older
• Anyone required to care for a disabled child or adult
• Anyone participating in an intensive, authorized medical treatment program for alcohol or substance abuse or addiction (including opioid addiction)
• Anyone enrolled in and compliant with the TANF JOBS program
• Anyone exempt from the TANF JOBS Program
• Anyone who is a single custodial parent of a child age 12 months or younger
• Anyone who is a single custodial parent caring for a child under the age of 6 for whom appropriate childcare is not available 
• Anyone who failed to meet the employment requirements for “good cause”, similar to those in the TANF JOBS Program

The American Heart Association is concerned about how the additional work requirements will impact Alabamans with, or at risk of, heart disease and stroke and their families. We have been speaking against the proposal, submitting public comment during both state level comment periods this year and now during the federal comment period. 

In a group public comment letter this month, we expressed some concerns to CMS that include: 

• The increased administrative burden on all patients likely will decrease the number of individuals with Medicaid coverage.
• People who are in the middle of treatment for a life-threatening disease, rely on regular visits with healthcare providers or must take daily medications to manage their chronic conditions cannot afford a sudden gap in their care.
• The current exemption criteria may not capture all individuals with, or at risk of, serious and chronic health conditions that prevent them from working. Even exempt enrollees will have to provide documentation of their medical condition validated by a medical professional, creating opportunities for administrative error that could jeopardize their coverage. 
• Administering these requirements will be expensive for Alabama and could divert resources from Medicaid's core goal - providing health coverage to those without access to care. 
• If beneficiaries comply with the new requirements, but no longer meet the eligibility criteria for the state's Medicaid program as a result of their increased earnings, Alabama proposes 18 months of Transitional Medical Assistance, which is a temporary and insufficient fix, as individuals could still lose coverage if they get caught up in the red tape trying to prove their continued compliance.

The American Heart Association is committed to preserving and protecting patients' access to affordable coverage through Medicaid. We know the connection between health coverage and health outcomes is clear and well documented. Americans with cardiovascular disease risk factors, who lack health insurance or are underinsured, have higher mortality rates [1] and poorer blood pressure control [2] than their insured counterparts. Further, uninsured stroke patients suffer from greater neurological impairments, longer hospital stays, [3] and a higher risk of death [4] than similar patients covered by health insurance. 

To date, the Trump administration has approved work requirements in Arkansas, Indiana, Kentucky and New Hampshire, all of which have expanded Medicaid to include more low-income, childless adults. However, a federal judge blocked Kentucky's efforts this summer because it undermined Medicaid's core objective to provide health care to low-income citizens.

1 McWilliams JM, Zaslavsky AM, Meara E, Ayanian JZ. Health insurance coverage and mortality among the near-elderly. Health Affairs 2004; 23(4): 223-233.
2 Duru OK, Vargas RB, Kerman D, Pan D, Norris KC. Health Insurance status and hypertension monitoring and control in the United States. Am J Hypertens 2007;20:348-353.
3 Rice T,LaVarreda SA,Ponce NA, Brown ER. The impact of private and public health insurance on medication use for adults with chronic diseases. Med Care Res Rev 2005; 62(1): 231-249.
4 McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of previously uninsured adults after acquiring Medicare coverage. JAMA. 2007; 298:2886 –2894.