The impact of Alabama's proposed Medicaid work requirement on low-income families with children

Alabama is seeking federal permission through a Section 1115 Medicaid demonstration waiver to require parents and caregivers who rely on Medicaid to work 20 to 35 hours a week, prove they are looking or training for a job or do community service before receiving Medicaid. This proposal targets the very poorest and most vulnerable families with children in Alabama – many of whom will lose their health coverage, according to a new report by Arise Citizens’ Policy Project and the Georgetown University Center for Children and Families.

Alabama’s proposed work requirement and subsequent coverage losses would disproportionately affect mothers, African Americans and families living in rural communities. Many of these women will likely become uninsured, as employer-sponsored insurance for low-wage workers is sparse.

The proposal creates a Catch-22: Any parent working the 20 to 35 hours required would make too much money to qualify for Medicaid — but likely not enough to afford private insurance. An analysis of the state’s estimates finds that 8,700 parents would be removed from Medicaid in the first year alone. When their parents lose health coverage, children suffer. The families face increased debt, and children are less likely to visit the doctor regularly and more likely to become uninsured themselves. Children in these families are already disproportionately uninsured.

Click here to read Arise’s news release on the report.

Click here to read the full report.

'Alabama's new catch-22': Testimony from Arise's Kimble Forrister against Alabama's Medicaid work requirements plan

Arise executive director Kimble Forrister testified against Alabama’s proposed Medicaid work requirements waiver during a public forum on Monday, March 5, 2018, in Montgomery. Here is the full text of Forrister’s prepared remarks:

When we compare Medicaid’s waiver proposal to DHR’s welfare reform proposal in 1996, what’s most striking is Medicaid’s lack of data. How can we analyze the target population when Medicaid can’t give us information on the adults in the POCR (Parents and Other Caretaker Relatives) population?

I learned a lot when I served on Gov. Fob James’ Welfare Reform Commission. First, we analyzed Gov. James’ unjustified claims that the AFDC program (that was Aid to Families with Dependent Children, the cash welfare program now called TANF) incentivized teen pregnancy, and that AFDC was a budget-buster. In fact, it just didn’t make sense that any woman on welfare would get pregnant just to gain an additional $29 a month in welfare benefits. And with cash welfare amounting to one-half of 1 percent of the General Fund budget, it was hardly a budget-buster.

Again today, we hear unjustified claims from our governor. Gov. Kay Ivey says she wants to save taxpayer dollars and reserve Medicaid for the people who need it most. But who needs Medicaid more than the mother who’s trying to support two kids on $312 a month or less?

Even the woman who works 10 hours a week at minimum wage makes too much to meet this standard. And if this new policy “succeeds,” and she gets a 20-hour-a-week job, she is no longer eligible for Medicaid – and that defeats the whole purpose. Her new low-wage job is unlikely to provide health coverage. Her income is unlikely to be high enough to allow her to buy coverage on the marketplace. She will be caught in Alabama’s new catch-22.

Changes like this can be game-changers – but they can change the game in a bad way. We learned it the hard way in the 1990s. Well-meaning professionals in the Family Assistance section of DHR (the Department of Human Resources) assured us that there were three kinds of people among the 26,600 adult recipients (note that this was about a third of the POCR population):

  • There were those who were only using cash welfare as a temporary program that would help them get back on their feet, and they would be back in the workforce in a three to six months. They had data to show that this was a large share of the caseload. And apparently today’s Medicaid Agency is unable to do a similar analysis of the POCR caseload.
  • At the other end of the spectrum were the hardship cases who faced extreme barriers to employment, and the professionals assured us that they would be protected from harsh consequences. They truly needed the program. We would think that these are among the 4,000 to 5,000 adults now on TANF, about a sixth of the original population.
  • The professionals assured us that a middle group – between the job-ready at one end and the hardship cases at the other – were the people who just needed a kick in the pants to get off welfare and into a job, any job, and that it was easier to move up the ladder from any job than from no job.

This analysis makes some sense, but only in the context of an understanding of the barriers: women on welfare consistently said that in order to enter the workforce, they needed four things: jobs, child care, transportation and health care.

DHR in fact made some effort in these areas. People could count on a year of Medicaid coverage and child care when they took a job, and they even got a few months of cash welfare to ease the transition to work.

But we analyzed the data from the first year of implementation and discovered that the numbers didn’t match the theory. An economist on our staff did a regression analysis and discovered that the numbers in the caseload did not line up with the numbers moving from welfare to work. Instead, the lower caseload numbers lined up with the lower number coming in the front door, not the number leaving for employment.

The reality was, these women could not overcome the challenges of child care and transportation to even go to the job interviews that were required before they could get TANF benefits. The theory – that a kick in the pants would lead to a job – did not explain the numbers. The reality, played out for thousands of women across the state, was that some our most vulnerable people – young mothers who can’t access child care and transportation – were denied the $50 a week we provide in TANF benefits.

We would urge the Alabama Medicaid Agency to take a hard look at its theories and compare the theories to the numbers. Are you actually cycling a significant number of cases through a transitional period of difficulty between jobs? If so, you probably don’t need a big increase in administrative costs to get them to work.

Medicaid’s own projections show that some 57,000 people in the POCR caseload will be exempted from work requirements. But the administrative cost of making that determination will add significantly to our famously low-overhead Medicaid budget. It won’t be so low-overhead anymore.

The group that’s left – perhaps 17,000 people who are not job-ready and not hardship cases – is the group that’s at risk of essentially being kicked while they’re down. If you can’t arrange child care and transportation to start on the path to a job, you’re not getting help. You’re getting the front door slammed in your face.

Bottom line: In a state with 18.5 percent of its people in poverty, this plan proposes to put about 1.5 percent of its people under a microscope, expecting to find about 1/3 of a percent they can move off Medicaid. Gov. Ivey is proposing to put a huge administrative effort into forcing this 1/3 of a percent of the population into jobs, with the result that a few thousand mothers might get jobs, but they surely will no longer have health care.

If Alabama seriously wants to test its ability to move people from POCR to the workforce, why not propose a one-year pilot program that offers work supports without the penalties that remove their health care?

'Simply cruel': Testimony from Arise's Carol Gundlach against Alabama's Medicaid work requirements plan

Arise policy analyst Carol Gundlach testified against Alabama’s proposed Medicaid work requirements waiver during a public forum on Monday, March 5, 2018, in Montgomery. Here is the full text of Gundlach’s prepared remarks:

It is important for us to recognize that the people who will be affected by this proposed policy are exclusively the parents or guardians of children, often very young children. Over 90 percent of them are women. They are among the poorest people in Alabama, with an average monthly income of less than $400 for a family of three. These poor families are an extraordinarily vulnerable population to target for the potential loss of health care assistance.

Alabama offers few supports for people transitioning to work. While the waiver request says that people will be referred to supportive services, there is no reason to expect that they will be able to actually receive these services. Subsidized child care, in particular, is a necessity for a parent who works.

In Alabama, however, subsidized child care receives no state funding. As a result, most subsidized child care subsidies serve the highest priority categories, including foster children, children receiving protective services, and children who are in families that receive TANF (Temporary Assistance for Needy Families). In September 2017, there was a waiting list of over 1,000 children and significantly more pent-up need for subsidized day care. The same could be said for other support services, including job training and public transportation, which are essential job supports.

The waiver request says that people who can’t find services like transportation or child care will be exempt. But the way this section is written is particularly confusing and unclear. The waiver request says people “compliant with JOBS are exempt.” And it says that anyone exempt or deferred from JOBS (Job Opportunities and Basic Skills) will not be required to engage in work activities. To be either participating or exempt from JOBS, though, one must be receiving TANF.

There are around 4,000 adults receiving TANF and 75,000 people in the POCR (Parents and Other Caretaker Relatives) Medicaid capacity. While it appears to be implied, the actual language of the waiver request is silent or whether any of the other 71,000 participants not receiving TANF will be deferred if they don’t have child care or transportation.

The waiver request says the Medicaid work program would be “modeled” on the JOBS program. And the proposed memorandum of understanding with DHR (the Department of Human Resources) seems to indicate that non-deferred POCRs will actually be enrolled in the JOBS program or another program administered by DHR that is very similar to JOBS.

A critical element of the JOBS program is access to emergency and job support services, including auto repair, emergency housing assistance, transportation assistance, uniforms and other needs. One of the most important supports in the JOBS program is priority access to subsidized child care without having to be placed on a waiting list.

Will POCR recipients also become eligible for these TANF/JOBS-funded services? And if so, would those auxiliary services by paid for with the already inadequate TANF block grant? If so, this waiver proposes to try to expand services now covering 3,700 people to an estimated additional 17,000 individuals, further stressing an already underfunded JOBS program and reducing assistance now reserved for TANF participants mandated to participate in JOBS.

The waiver request says “every adult in the household” would be required to participate. If this is the case, is the plan to terminate the Medicaid of a compliant or exempt Medicaid recipient if a non-recipient who lives in the same household doesn’t participate? Besides the deep unfairness of punishing the Medicaid recipient for the behavior of another household member, this policy empowers the non-recipient to use the threat of the loss of insurance to abuse and control the Medicaid recipient.

Ultimately, this waiver request raises more questions about what is being proposed than it answers. Most of the answers will apparently be found in the yet unspecified MOUs with the Department of Human Resources and the Department of Labor – MOUs that may not be available to the public before they are implemented.

We need not to overlook that the intent of this proposal is to take health insurance away from targeted women who are unable, for whatever reason, to comply with employment and training activities. The request speaks to the benefits of work for children and families, and we certainly agree that, with the right supports, families are better off when there is earned income.

But I cannot see how the loss of parental health insurance can possibly benefit children. If Mom cannot afford her asthma medicine or her insulin because her Medicaid has been discontinued, then she gets sick and can’t work, or ends up in the hospital, or doesn’t buy the food, clothing or other necessities for her children in order to buy the medicine she needs. Any of these outcomes will hurt the family and the children.

The dignity of work, and the income it produces, does of course benefit families. But to use health care as the stick to force work efforts, without providing the supports that make work attempts successful, is simply cruel and will result in no outcome other than poorer, more desperate and less healthy Alabama families.

Four reasons to oppose work requirements for Alabama Medicaid

(1) The vast majority of enrollees are children or otherwise exempt. Medicaid covers about 1 million Alabamians (roughly one in every five people in the state), and most of them are children. Almost all of the rest are seniors, pregnant women, or people with disabilities who would be exempt from work requirements. Only about 7.5 percent of enrollees – roughly 75,000 people in the “parent and other caretaker relative” category – could be subject to a requirement.

(2) Many Alabamians who would face work requirements have serious barriers to employment. Nearly 90 percent of the 75,000 parents and caretakers covered by Alabama Medicaid are women. Many are going to school or caring for young children at home. Medicaid work requirements would not make child care, transportation or job training more accessible for them.

(3) Adults who lose Medicaid would fall into the coverage gap. Most states seeking to impose work requirements have expanded Medicaid for working-age adults. But Alabama hasn’t. About 300,000 Alabama adults are caught in a coverage gap. They earn too much for Medicaid but too little to receive subsidies for Marketplace coverage.

(4) Work requirements would create a catch-22 for people in poverty. Alabama parents can’t qualify for Medicaid if their income is above 18 percent of the poverty line. Someone working just 20 hours a week at minimum wage earns too much to qualify for Medicaid in Alabama. It’s unfair to require people to work to keep health coverage, only to take it away when they do.

By Chris Sanders, communications director, and Jim Carnes, policy director. Last updated Jan. 26, 2018. Originally appeared in Arise’s January 2018 newsletter.

New Medicaid hurdles would create barriers to health in Alabama

The Trump administration is encouraging states to impose work requirements on “non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability.” State Medicaid Commissioner Stephanie Azar told lawmakers the agency likely will seek approval for such a requirement this year. SB 140, sponsored by Sen. Arthur Orr, R-Decatur, and HB 331, sponsored by Rep. Arnold Mooney, R-Birmingham, would mandate this policy and place other statutory conditions on Medicaid eligibility. The bill would:

  • Require Alabama Medicaid to “request approval of the firmest but nonetheless most reasonable work requirements allowed” by the federal government.
  • Require semi-annual, rather than annual, eligibility verification for Medicaid beneficiaries, including a review of financial resources.

Unlike Alabama, most states seeking to impose work requirements have expanded Medicaid to cover low-income working adults. Most of Alabama’s Medicaid beneficiaries are children in low-income families. The next largest groups are people with disabilities, low-income seniors and pregnant women. Only about 75,000 parents and other caretaker relatives of Medicaid children qualify for Medicaid coverage. Nearly 90 percent of them are women. The income limit for Medicaid parents is just 18 percent of the federal poverty level ($307 per month for a family of three).

SB 140 and HB 331 leave many questions unanswered:

  • Given Alabama’s stringent Medicaid eligibility for adults, what group or groups will a work requirement target?
  • What training and work supports will Alabama offer to help affected beneficiaries find and keep jobs? For example, will the state’s wait-listed program for subsidized child care be expanded?
  • Given Alabama’s strong support for children’s health insurance, how will the state mitigate the harm that occurs to children when parents lose coverage?
  • How will the work requirement apply to parents who are in school? To those awaiting disability determination? To those who lack reliable transportation? To those who live in areas with high unemployment?
  • Is Medicaid equipped and funded to monitor compliance with the new requirements while making sure no individuals eligible for Medicaid fall through the new procedural cracks?
  • Since the Affordable Care Act ended asset tests for Medicaid, how does a semi-annual verification of “financial resources” comply?
  • If health coverage is a privilege for working people, why hasn’t Alabama expanded Medicaid to cover low-income workers who don’t get employer coverage and can’t afford private plans?

BOTTOM LINE: Creating work requirements and more eligibility hurdles for Alabama Medicaid would erect unreasonable barriers to health care. Making Alabama’s bare-bones Medicaid even more stringent is the wrong way to promote a healthier workforce.

Click here to read a PDF version of this fact sheet.

Posted Jan. 22, 2018. Last updated Feb. 1, 2018.

Keep kids covered: Congressional inaction threatens ALL Kids coverage for Alabama children

Federal funding for the Children’s Health Insurance Program (CHIP) has expired, and health coverage for millions of American kids is at stake. Despite a history of strong bipartisan support, Congress allowed a Sept. 30 deadline to pass without renewing federal funding for the program, which offers affordable coverage for children whose low- and moderate-income families don’t qualify for Medicaid.

CHIP covers about 150,000 children across Alabama, through both ALL Kids and Medicaid. ALL Kids officials say they have enough funding on hand to maintain coverage until early 2018. But continued uncertainty in Congress may force Alabama to start sending termination letters to many ALL Kids families as soon as next month.

ALL Kids has been a huge success story for Alabama. It was the first plan in the country to win federal approval after Congress authorized the creation of state CHIPs in 1997. Alabama’s uninsured rate for children at that time was 14 percent. Two decades later, that rate is less than 3 percent. It’s a proud achievement that affirms ALL Kids’ consistent performance as a national model program. Alabama also has benefited recently from extra CHIP funding through the Affordable Care Act (ACA). A temporary boost in federal matching funds under the ACA has meant that Alabama has not had to contribute any state money toward CHIP for the past two years. The future of this boost is another question Congress faces on CHIP’s funding.

Failure to renew CHIP funding would put children and families at risk:

  • Nearly 9 million children nationwide, including more than 150,000 in Alabama, receive essential health coverage through CHIP.
  • Families pay a reduced, income-based premium for CHIP, which keeps health coverage in reach for families who otherwise couldn’t afford insurance.
  • The threat of lost coverage puts unnecessary strain on hard-working families.

BOTTOM LINE: Congress needs to lift the cloud of uncertainty over children’s health coverage and renew full CHIP funding for five years.

Click here to read a PDF version of this fact sheet.

What's at stake for Alabama Medicaid?

Our state simply can't afford any more Medicaid cuts. Alabama's Medicaid program is essential, and it has already been cut to the bone. More than 1 million people -- or one in five Alabamians -- have Medicaid coverage, and almost all of them are children, seniors, pregnant women, or people with disabilities. Medicaid covers thousands of people in every Alabama county, and cuts like the federal funding cap that Congress is considering would be devastating for low-income Alabamians and rural communities across the state.

This fact sheet explains who is covered under Alabama's barebones Medicaid program, how Medicaid cuts would hurt vulnerable Alabamians and how slashing Medicaid would deal a serious blow to local economies and the health care infrastructure that benefits our entire state.

A long-term budget fix includes Medicaid expansion

As Alabama lawmakers grapple to prevent devastating Medicaid cuts, the time is right to address a related threat to our state: the health coverage gap. Nearly 200,000 Alabama workers we depend on every day – in agriculture, food service, retail, home health and other fields – have no access to regular health care. They have no health insurance because their employers don’t offer it. They earn too much to qualify for Medicaid but too little to qualify for federal tax credits to buy private plans. As a result, they often struggle to work while dealing with health problems that sap their productivity, add stress to their households and get worse without timely care.

Closing the coverage gap would not only save lives and help working families; it would stabilize the budget and boost our economy. This fact sheet by policy director Jim Carnes takes a closer look at how Medicaid expansion would benefit Alabama's health, quality of life and economy.

Medicaid RCOs: Better care, better health, lower costs

Under the Medicaid reform plan approved by the Alabama Legislature in 2013, regional care organizations (RCOs) will manage patient care to improve efficiency, accountability and health outcomes. Federal approval of the plan in February 2016 was a huge vote of confidence in Alabama’s ability to achieve these goals. Below are short answers to basic questions about RCOs. (Click here for a PDF version of this overview of Alabama's RCO reforms.)

What are RCOs?

  • RCOs (regional care organizations) are networks of doctors, hospitals and other health providers serving Medicaid patients in each of five new Medicaid regions.
  • As community-based nonprofit organizations, RCOs are governed by boards representing a broad range of health care stakeholders and assisted by citizens’ advisory committees reflecting the diversity of the patients served in each region.
  • By law, Alabama Arise and the Disabilities Leadership Coalition of Alabama nominate consumer representatives for each RCO’s citizens’ advisory committee.

How are RCOs different from traditional Medicaid?

  • The new plan changes Medicaid from a system that rewards volume of medical services to one that rewards better care and cost savings.
  • Currently, Medicaid patients seek health care on their own, without case management, and Medicaid reimburses providers for services rendered. Under the new plan, RCOs will receive a “capitation payment,” or flat yearly amount, to manage and provide appropriate, quality care for each patient they serve.
  • Through case management, RCOs will work with patients to make sure they receive timely preventive and primary care, comply with doctors’ orders, keep chronic conditions under control and avoid expensive emergency room visits.
  • RCOs emphasize the right care, at the right time, in the right setting

What does this mean for Medicaid patients?

  • The RCO system builds upon Alabama’s successful Patient Care Network model, giving each Medicaid patient a primary care physician.
  • Better access to primary care means better coordination of medical services, better management of chronic conditions and better tracking of patients’ health progress.
  • Patients now will have a “home base” for all their health care needs.

How will RCOs impact the General Fund budget?

  • The capitated payment to RCOs will make the Medicaid budget more predictable.
  • The RCOs – not the state – will bear the financial risk for the cost of providing health care to Medicaid patients in that region.
  • As patients receive better coordinated and more efficient care, RCOs will “bend the Medicaid cost curve,” reducing long-term growth in the program’s budget.

What is the future of Medicaid in Alabama?

  • Medicaid is the cornerstone of the health care system on which we all depend.
  • RCOs are an important investment in Medicaid. With this approved reform, Alabama can move forward with its plan to enhance care coordination and bend the cost curve.
  • By properly investing in Medicaid and the RCO model, the Legislature can take the final steps in the reform process it began in 2013.

What’s next?

  • Health care providers and advocates are working with the Legislature to ensure that Medicaid’s budget is adequate to seize this unique opportunity for achieving better health care, better outcomes and lower costs.
  • After two years of design and development, RCOs are on track to begin operation by Oct. 1, 2016.

Posted Feb. 26, 2016.

Special enrollment periods for health coverage

Initial open enrollment for coverage in the Health Insurance Marketplace has ended, but you still may be able to sign up for a plan. Alabamians who experience certain life events may qualify for a Special Enrollment Period without waiting until the next open enrollment period (Nov. 15, 2014, through Feb. 15, 2015).

This issue brief looks at the life changes and other opportunities that may allow people to enroll in Marketplace coverage throughout the year.

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