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Reyna Ulibarri depends on Medicaid to cover treatment for serious injuries sustained in a car accident. Photograph by Joe Mahoney

Health Care

Medicaid Work Requirements Could Mean Fewer People Insured, Higher Costs

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Two years ago, 40-year-old Reyna Ulibarri of Denver was driving on I-70 when her automobile was struck in a hit-and-run and she suffered a traumatic brain injury. At the time, she was in the final stages of pursuing her doctorate in sociology at Indiana University.

Given her modest salary teaching as an adjunct at both Metropolitan State University of Denver and University of Colorado, Ulibarri was enrolled in Health First, Colorado’s Medicaid program, prior to her automobile accident. Even before the incident, Health First was covering Ulibarri’s medications to manage several chronic conditions that would otherwise cost her nearly $300 monthly.

More than 400,000 people have been added to the Health First program since Colorado last expanded Medicaid coverage, in 2014. Many of those now covered—especially childless adults like Ulibarri—were previously uninsured, as the Obamacare-related expansion increased income eligibility to 138 percent of the federal poverty level.

While Ulibarri credits Health First with covering tests and treatments vital to her recovery—including extensive imaging and regular visits to a neurologist, physical therapist and occupational therapist—she is also worried she may lose her health insurance due to policy changes in Washington, and a related legislative attempt at the end of March in Colorado.

The Trump Administration said in January that it would allow states to impose work requirements on some adults enrolled in Medicaid. So far, nearly a dozen states have sought approval to impose these requirements, with two states—Indiana and Kentucky—recently receiving approval.

A bill introduced in March in the Colorado Senate set the stage for work requirements for Medicaid enrollees in Colorado. The bill died in its first committee, with one Republican lawmaker joining Democrats to prevent it from advancing. The failed legislation followed recent comments by Democratic Governor John Hickenlooper suggested he is open to adopting such rules. Hickenlooper said there are “a lot of people very frustrated when they think that people are freeloading on the system.”

Moves to impose work requirements have set off warning bells for many Medicaid patients and advocates in Colorado, as other legislative efforts may emerge in 2019 or beyond.

The requirements in the failed Colorado Senate bill would have only applied to “able-bodied” people. But the term can be misleading, as it is often used to refer to anyone who has not received formal disability recognition from the Social Security Administration. Many people who do not have official disability status are struggling with health conditions that prevent them working full time—or sometimes at all.

About 35 percent of Medicaid enrollees in the nation have been found to be out of work due to disability or illness, according to the Journal of the American Medical Association. This includes people like Ulibarri, who, despite the severity of her injury, has yet to be awarded Social Security Disability Insurance. She says she is terrified at the thought of losing her Medicaid coverage if she is forced to work to maintain coverage, but is physically unable.

“It’s hard to be a productive member of society when you have chronic health conditions that limit you,” says Ulibarri. “I was ready to work hard, full time, to afford health insurance and start paying my dues to society… but my injury makes it impossible at this time.”

Adam Fox, the director of strategic engagement at the ‎Colorado Consumer Health Initiative, a nonprofit health care advocacy group based in Denver, believes imposing work requirements under Medicaid is ultimately a backdoor way of cutting the program, while exploiting the false narrative that people on it are simply gaming the system.

“Work requirements serve no other purpose than to strip health care away from people that need it,” says Fox. “[It] would only limit access to coverage and essential health services by adding administrative red tape.”

Julie Reiskin, executive director of the Colorado Cross-Disability Coalition (CCDC), a Colorado Trust grantee that advocates for justice for people with disabilities, says work requirements could push some people off Medicaid if the employment they find pays more than the income threshold. In theory, this may sound like a good thing—but if their employer does not offer comparable health insurance benefits, it could force them to either purchase costly insurance, or remain uninsured and pay for health expenses out of pocket.

“We strongly support work incentives for people on Medicaid, but oppose work requirements for [many] reasons,” says Reiskin.

Many CCDC members are in situations where they can only work part-time due to illnesses that do not officially qualify them as disabled, says Reiskin. For instance, she describes a 20-something man CCDC serves who has mental health issues that require periodic hospitalizations that would make traditional work nearly impossible, even though he is not considered disabled by Social Security standards. However, the man is able to work part-time when he is feeling better.

For those on Medicaid who aren’t suffering from a debilitating illness or injury, Reiskin says that they are usually either in school or serving as the primary caretaker for a young child or sick family member. (According to the Colorado Department of Health Care Policy and Financing, which oversees Health First, 76 percent of nonelderly adults and children enrolled in Medicaid in Colorado live in a family where at least one individual already works. Of those nonelderly adults on Medicaid who don’t work, 18 percent are students and 28 percent are taking care of family members.) This includes 52-year-old Robin Bodluc of Boulder, the primary caretaker for her 64-year-old husband Bruce, who was diagnosed with primary progressive multiple sclerosis 23 years ago.

“It would be hard to find a job that would allow me to call out or leave at any given moment if an attendant called out sick or if there is any sort of crisis, such as a broken wheelchair or Bruce running a fever,” says Bodluc, who worked as director of a state agency prior to becoming a full-time attendant to her husband.

Bodluc is paid through Health First to work 40 hours per week as one of Bruce’s seven personal care attendants (he requires 24-hour care), and she is therefore not as likely to be impacted by work requirements should they be mandated by the state. But she notes that many others are not so lucky.

“Many family caregivers are not paid and they are unable to work outside of their caregiving responsibilities,” says Bodluc, who is also covered under Health First. “The Medicaid expansion has been [our] first access to health insurance in many years, so any work requirement must also acknowledge unpaid work.”

Both Fox and Reiskin believe that administering work requirements under Medicaid in Colorado would cost more time and money than it would likely save.

“Medicaid work requirements are… quite expensive and inefficient to administer from a state perspective,” says Fox, who cites a report that the administrative costs for implementing Medicaid work requirements in Kentucky is estimated to have an annual price tag of $186 million: “[This] actually means Kentucky will spend more money to cover fewer people.”

Reiskin cites Colorado’s well-documented trouble keeping up with the current Medicaid program for working adults with disabilities as indicative of the challenges the state could experience.

“The administration of [Medicaid work requirements] would be a nightmare,” says Reiskin.

Ulibarri says losing Medicaid would make it impossible to live independently.

“I don’t know how I will survive if I lose my access to treatment for my traumatic brain injury and my chronic health conditions,” says Ulibarri. “Having access to health care has given me opportunities to better myself, which benefits my community.”

Laura Kiesel

Freelance Reporter
Boston, Mass.

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