On the horizon

Will Republicans push Medicaid work requirement?

Photo by Austin Goode on Unsplash

A few years ago, when Iowa Republicans pitched a plan to impose work requirements on Medicaid recipients, critics called it punitive, and it got little traction.

Now, Republicans have introduced it again.

However, the idea has gotten little notice — which is probably what happens when the idea gets included in a bill that also proposes to take away fresh meat from poor people on food stamps.

After an uproar, Republicans backed off the plan. But so far, I see no indication they have shied away from the idea of requiring the state’s Department of Health and Human Services to apply for a waiver from the federal government to require that some people enrolled in Iowa’s Medicaid program spend 20 hours per week involved in what the bill calls “community engagement.”

That means working, volunteering or taking part in the state’s PROMISE JOBS program.

There are exceptions, such as for pregnant women and those who are “physically or mentally unfit” to work. But otherwise, enrollees in the Iowa Health and Wellness Plan, which covers people between 19 and 64 who are very low income, would need to fulfill the work requirements in order to qualify.

The state’s Health and Wellness Plan was formed to expand Medicaid coverage under the Affordable Care Act.

This isn’t the first time Republicans have tried to do this. The GOP-controlled Senate passed similar bills in 2019 and 2020, though the measures went no further than that.

I would not expect the Biden administration to approve a waiver request even if Iowa sends one in. It’s notable the administration killed a work requirement in Ohio in 2021.

Still, if a Republican were to win the White House in 2024, that could change things. In 2018, the Trump administration, in a departure from previous administrations, issued guidance inviting states to apply for waivers to impose work requirements and approved them in several states. (The courts struck down many of the waivers and the U.S. Supreme Court dismissed pending challenges last year, according to the Kaiser Family Foundation.)

Medicaid work requirements are controversial.

Supporters say the expansion of Medicaid under the Affordable Care Act has led people to drop out of the labor force, and that a work requirement would eliminate the disincentive to reduce hours or avoid employment. They also say that it would lead to greater economic gains in the long term for people on Medicaid.

Critics, however, say health care coverage actually makes it more likely people will be employed and removing coverage would be a barrier to work. They point out the experience in Arkansas, where a work requirement was put in place in 2018 and it led to confusion and thousands of people losing coverage. And, they add, there was no corresponding increase in labor force participation.

The Kaiser Family Foundation reported last year that before the pandemic 63% of non-elderly, non-disabled adults on Medicaid alone were already working full- or part-time, and that among those not working, lack of childcare, illness or school attendance were among the reasons they weren’t employed.

“It’s just disingenuous to think that they don’t want to work and aren’t working,” said Kelli Soyer, who is with Common Good Iowa.

In 2019, an analysis by the Legislative Services Agency estimated 57% of Iowa Health and Wellness Plan members would be exempt from the work requirement proposed back then. At the time, there were nearly 167,000 members on the Health and Wellness Plan. That number has grown to 246,000 in fiscal year 2022, according to the Reynolds administration. Much of that growth has come during the pandemic.

The 2019 LSA analysis said the work requirement would increase state operating costs by $5 million in fiscal 2021 and $12 million in fiscal 2022. The agency also said it was not able to estimate whether enrollment in the program would be affected, but that state savings would be “minimal” since 90% of costs were covered by the federal government.

It’s impossible to predict in advance what impact this work requirement would have in Iowa. But the Kaiser Family Foundation reported that “available implementation data suggests that Medicaid work and reporting requirements were confusing to enrollees and result in substantial coverage loss, including among eligible individuals.”

At some point, I expect this proposal will get more attention. After all, even though the Biden administration won’t grant a waiver, this bill requires that the state keep trying “until federal approval is received.”

Postscript

Republican lawmakers are on the cusp of sending a K-12 education spending bill to Gov. Reynolds that calls for a 3% increase in basic state aid. That’s higher than what Reynolds proposed, but less than what Democrats and school groups wanted.

The Senate passed the bill last week. It still is pending in the House. Republican leaders there also proposed 3%.

There was a missing piece, however, in the Senate approved bill that will be of special interest in the Quad-Cities.

There was no money for addressing the per pupil inequity.

The inequity, which has existed in state law for years, allows some districts in the state to spend more than others, with the maximum gap once as high as $175 per pupil.

This became a big deal in Davenport some years back. Former superintendent Art Tate once flouted state law, drawing attention to the problem, while parents and students demonstrated at the Capitol demanding change.

The Legislature responded somewhat, led by the Senate. Over the years, lawmakers began chipping in small amounts of money to close the gap. It now stands at $140 per pupil.

It wasn’t much, but at least it represented some momentum.

But not this year. At least not so far.

It is still possible legislators could do something, and education advocates are asking them to do so.

It’s more than Davenport that has a stake in this issue. There are more than 200 districts across the state that are at the state minimum, according to the Urban Education Network of Iowa.

Has the momentum been stopped?

We’ll just have to wait and see whether anybody in the Legislature steps up to keep it going.

Editor’s note: This post has been updated to reflect that the K-12 spending bill still is pending in the House. An earlier version of this article incorrectly said the measure had passed both chambers.

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