Recent guidance from the Centers for Medicare & Medicaid Services (CMS) allows states to require Medicaid recipients to work in order to receive their health coverage.  If Florida were to adopt such an approach, as a growing number of states have begun to do, thousands of residents would likely lose their access to health care.1

While the premise of work requirements, that they will support the development of workplace skills and economic independence, may sound appealing, in fact, it is fundamentally flawed.  First, it assumes that Medicaid recipients are not working, when in fact, 61% of adult Medicaid enrollees in Florida work.  Nationally, of those who aren’t working, more than 80% are in school or report an illness, disability, or caregiving responsibilities that keep them from working.

Additionally, work requirements subject people to burdensome paperwork and documentation requirements, which too often lead ultimately to loss of coverage.  In other words, work requirements cause recipients who are already working, or are duly exempt from work, to lose their Medicaid because of administrative errors, and/or the system’s inflexibility (e.g. late paperwork, administrative errors, insufficient work hours in a given month, or a brief spell between jobs).  The remaining individuals, who are neither working nor ill, disabled, or caregiving, likely don’t lack motivation to work, but supports that make work possible such as child care, and access to transportation.  Further, in a state like Florida, that has not expanded Medicaid; the pool of able-bodied adults who would be subject to work requirements is quite limited, further underscoring the illogic of work requirements here.

Having health care helps people work and look for work.  Ironically, taking it away will make it more difficult for many people to keep their jobs, or find a new job.  Anticipated coverage losses that would come with work requirements will make health outcomes worse, access to care more difficult, and will make any growth in employment rates among recipients highly unlikely.  In fact, a recent study of the first ever Medicaid work requirements, implemented in Arkansas found precisely these outcomes: thousands of people lost their Medicaid while there was no significant change in employment.  Work requirements, it turns out, don’t work.

If you or someone you know is on Medicaid and want to learn more about this potential change to the Florida program, please contact us.

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1 When work requirements have been challenged in federal court, they have been twice struck down, in Arkansas and Kentucky.

Background
Florida’s Medicaid program, public health insurance for certain low-income individuals, is jointly funded by the state and federal governments.  Regardless of the program’s annual costs, federal dollars cover over 60% of the bill.  Thanks to this reliable support, the State can meet the needs of all those who are eligible.  But this could change.

The federal government is currently encouraging states to elect to “block grant” their Medicaid program.  In contrast to the current guarantee of a “federal match,” a block grant would cap the federal contribution to Florida’s Medicaid program at a fixed amount.  Beyond that cap, the state would bear all responsibility for program costs.  The Administration’s move represents a major cut to federal Medicaid spending, with planned savings of $1.5 trillion from the national Medicaid budget over ten years.  To lure states into accepting a potentially massive loss in necessary funding, the Administration is promising increased flexibility in the Medicaid program.  But this is a misleading “inducement,” as states already have significant program flexibility.  What Florida needs is not more flexibility but a reliable funding partner in the face of growing demands for health coverage.

Status and Impact
Florida’s Medicaid program currently guarantees coverage for children in low-income families and very low-income parents of minor children, pregnant women, and individuals who are blind, aged, or disabled. Over 4 million Floridians rely on Medicaid for their health care.  If Florida opts-in to capped Medicaid funds, a budget shortfall will be inevitable.  While the federal government will save money, the state’s costs will balloon.  Medicaid in Florida already has one of the country’s lowest per enrollee spending rates.  When the state decides it is unwilling or unable to take on additional costs, it will be forced to take ruthless measures: cut eligibility, reduce benefits, and/or establish waiting lists.

Florida’s residents already have serious economic challenges and health care needs that underscore the potential negative impact of a Medicaid block grant.  For example, Florida is home to over 800,000 children living in families below the federal poverty level, has the second largest waiting list in the country for severely disabled residents requiring home and community based services in order to avoid institutionalization, and is tied for first among the states for the highest portion of senior residents.  The state has one of the nation’s highest rates of HIV infection and a high rate of drug overdose mortality, and will be among the first in the nation to experience the wide-scale health impacts of climate change.

Capping federal health coverage funds will mean that many of these people, and likely those with the most expensive care needs, will find themselves without coverage for the care they require.  A Medicaid shortfall would also threaten the state’s ability to cover high-cost prescription drugs, to address a public health emergency like the opioid epidemic or Zika, or to meet the needs of Floridians in an economic downturn.  In short, a Medicaid block grant would spell disaster for the health of state residents and the viability of the providers who serve them.

Next Steps

• It is important to educate stakeholders and Florida legislators about the long-term impact of block granting Medicaid in Florida. They need to ask and answer these questions:  
  How would a block grant impact the children/people with disabilities who rely on Medicaid?  How would it affect access to mental health and substance use services?  How would it impact community providers that depend on Medicaid payments?
• Florida decision-makers need to see not just data and budgets, but the faces and the stories of individuals and families who rely on Medicaid.  We are collecting stories of those who would be most impacted in order to educate about the risks of a Medicaid block grant.  If you or a loved one depend on Medicaid, and you worry about how a block grant might endanger the care and services you receive, please be in touch.
  

On June 14, 2019, the U.S. Department of Health and Human Services officially published proposed changes to the nondiscrimination regulations under Section 1557 of the Affordable Care Act (ACA).1 The announcement triggered a 60-day public comment period. Section 1557, the nondiscrimination provision of the ACA, expands long-standing federal civil rights protections to certain healthcare programs and activities. The proposed rule changes will negatively impact multiple at-risk populations. Among other revisions, the changes would:

• Exempt most health insurance companies from nondiscrimination language
• Allow hospitals and providers to deny care based on religious beliefs
• Eliminate references to “sexual orientation” and “gender identity” as well as “sex stereotyping” virtually erasing LGBT protection
• Undo protections for HIV positive individuals that resulted from a complaint originating over HIV drug price inflation in Florida
• Remove the requirement for informing limited English proficiency (LEP) individuals of the availability of language assistance services

Potential Impact
Health care policy professionals, providers, and advocates are weighing in on how these changes negatively impact women’s reproductive healthcare access, as well as healthcare access for the LGBT, HIV+, and LEP populations. Raising the stakes for Florida, the state ranks 3rd for size of Medicaid population,6 10th for highest LGBT population percentage7 and 3rd highest for HIV infection rate in the United States.8 Additionally, Florida’s LEP population ranks 4th largest in the country with 2.1 million individuals.  

Florida Health Justice Project (FHJP) Next Steps
Alongside national, state and local partners, FHJP will be submitting official comments to the Department of Health of Human Services detailing the potential negative impact of the proposed changes on Floridians and discouraging implementation. In the coming days, FHJP will be gathering data and conducting research to inform our comments and conclusion. In addition, FHJP will share our research with other interested entities and encourage our partners to formally submit comments as well. Please contact Timothy Loftus, M.D., FHJP Law Clerk, at tloftus@law.miami.edu for questions.