CLEVELAND, Ohio – The Ohio Department of Medicaid soon will submit its proposed Medicaid waiver to the federal government, hoping to gain approval to apply work requirements to the Medicaid expansion population.

The waiver requires most able-bodied adults to work or participate in a sanctioned community engagement activity, like Supplemental Nutrition Assistance Program (SNAP) education and training activities, for 80 hours monthly to be eligible for Medicaid.

State think tanks, medical associations and local officials oppose the waiver, saying the work requirements would make healthcare less accessible, cost millions to implement and disproportionately affect black communities.

“I’d be much more comfortable with a program that offered support to people to find employment. I think tying their Medicaid eligibility to that isn’t particularly helpful,” said John Corlett, president and executive director of the Center for Community Solutions, a Cleveland-based think tank, and former state Medicaid director. “We actually think the program could cost more and end up covering less people.”

Cost

Community Solutions estimates the new work requirement would cost county governments $380 million over a five-year period because of the administrative burden of providing case management services to 200,000 new enrollees.

David Merriman, assistant director of the Cuyahoga County Department of Health and Human Services, estimates the new requirements would cost the county more than $10.8 million to administer. That’s more than any other county in the state, according to Community Solutions data.

Merriman, in testimony to the state, voiced concerns about how the state plans to compensate counties for the cost of the waiver.

“Will this be an unfunded mandate that requires counties to financially support? Is this a budget-neutral initiative if it costs counties local funds to implement?” Merriman said.

Access to healthcare

The Center for Health Affairs, a non-profit hospital association that represents Northeast Ohio hospitals like the Cleveland Clinic, MetroHealth and University Hospitals, questioned the state’s estimate that only 18,000 of the 700,000 Ohioans covered by the Medicaid expansion would be unenrolled under the new requirements.

“These new requirements create an obvious barrier to accessing healthcare for the consumer. Simply put, the success of the current proposal relies on a number of assumptions which ignore the practical application of this process and how severely it would deter enrollment,” the Center said in comments submitted to the state.

When the state implemented similar work requirements for SNAP, it estimated 134,000 people would lose eligibility. In reality, nearly 370,000 Ohioans were disenrolled, according to Loren Anthes, public policy fellow for Community Solutions.

And putting additional administrative responsibilities on already swamped counties could create a bottleneck for the entire Medicaid system, which covers pregnant women and children among other vulnerable populations, Corlett said.

“If this program creates churn, it will make it more difficult for people to get back into coverage,” Corlett said. “It risks upsetting the entire program.”

For example, Monica Starks of Bedford Heights returned to work as an adjunct sociology professor in March after being off for 1-1/2 years after suffering a stroke. Starks, 46, has end-stage renal failure, a kidney disease and relies on Medicaid for her regular dialysis treatments.

Right now, she’s only teaching one class because of her health.

“One of the benefits of the type of job that I have is it works well with my health,” Starks said. “It’s difficult to work 40 hours a week and do dialysis five days a week.”

She was able to get disability benefits after her stroke but worries what would happen if she were to fall off the Medicaid rolls for some reason.

“I’d probably die because I wouldn’t be able to afford dialysis. There’s no way I could afford dialysis on my own,” Starks said.

But overloaded systems can be burdened by churn, and people often fall in and out of the system, explained Steve Wagner, executive director of UHCAN Ohio, the Universal Health Care Action Network.

“There’s going to be bureaucracy and red tape no matter what, even if they meet one of those exemptions,” Wagner said.

Racial disparity

LaQueta Worley, who lives in the Union-Miles neighborhood of Cleveland, has tried to get on disability since last July, when she had surgery on her foot. For years, she’s had problems with her feet, dealing with bunions and heel spurs.

She had to quit her job as a school crossing guard and as a home healthcare aide because she had trouble standing and walking for long periods of time.

“It was hard,” said Worley, 45, who first started working when she was 14. “I can’t work now.”

She relies on the Greater Cleveland Regional Transit Authority, using bus passes she gets through various programs, to get around, and on her friends and family to help her with bills.

“The way I’m making it now, I depend on friends and family,” she said.

For medical concerns, she turns to Medicaid.

But as a resident of Cuyahoga County, Worley wouldn’t be exempt from the Medicaid work requirements proposed by the state.

“This is the wrong way to go about helping people get out of poverty. It’s bad policy,” said Wendy Patton, senior project director for Policy Matters Ohio, a liberal think tank.

As drafted, the waiver excludes able-bodied adults living in counties with high poverty rates, which excludes Cuyahoga County. These same 26 counties are also exempted from SNAP and Able-Bodied Adults Without Dependents (ABAWD) work requirements.

While Cuyahoga County doesn’t meet exemption requirements based on poverty levels, cities in the county like Cleveland, Euclid and Maple Heights all would, if the state were to base the program on municipalities, rather than counties. As it stands, the county-based structure benefits predominantly white, rural communities and excludes urban areas with black populations, according to Corlett.

“The current Medicaid waiver proposal, and its narrow criteria for unemployment exemptions, doesn’t treat these high unemployment communities the same as largely white communities in other parts of Ohio,” Corlett wrote in a policy brief.

What happens next

The state Medicaid office doesn’t yet have an exact date that it will submit the waiver, and is currently reviewing input from the public comment period, which ended March 18, officials said.

If granted a waiver, Ohio would be the fourth state, following Kentucky, Indiana and Arkansas, to gain approval from the Trump administration to enact work requirements. It would go into effect July 1.

In January, the Centers for Medicare & Medicaid Services issued guidance to state Medicaid directors encouraging them to apply for waivers to establish work or community engagement requirements for Medicaid. Ohio expanded Medicaid to cover an additional 700,000 Ohioans under the Obama administration.

Just the facts

• Ohio’s proposed waiver requires most able-bodied adults to work or participate in a sanctioned community engagement activity for 80 hours monthly to be eligible for Medicaid.
• Of the estimated 700,000 Ohioans covered by the Medicaid expansion, the state estimates 18,000 will be disenrolled because of work requirements. Critics say that number is too low.
• The Center for Community Solutions estimates the new work requirement would cost county governments $380 million over a five-year period because of the administrative burden of providing case management services to 200,000 new enrollees.
• In January, the Centers for Medicare & Medicaid Services issued guidance to state Medicaid directors encouraging them to apply for waivers to establish work or community engagement requirements for Medicaid.