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Medicaid work requirements are leaving more Americans uninsured, Harvard study says

Researchers looked at 3 states with different policies and found a risk of low-income patients staying or becoming uninsured due to work requirements

Jeff Lagasse, Associate Editor

Current experimental approaches in Medicaid programs -- including requirements to pay premiums, contribute to health savings accounts, or to work -- may lead to unintended consequences for patient coverage and access, such as confusing beneficiaries or dissuading some people from enrolling, according to a new study from Harvard T.H. Chan School of Public Health.

The findings are a signal that healthcare executives should listen closely to because they potentially foretell more uninsured patients showing up at the hospital as policies change around the country. 

While the authors found that any kind of Medicaid expansion would benefit public health by leading to improved care access and quality, some of the benefits may be at least partially compromised due to some of the approaches being used. 

Under the Trump Administration, which has prioritized increased flexibility for state Medicaid programs, some states have been experimenting with these new approaches. Most recently, the Centers for Medicare and Medicaid Services approved proposals from Kentucky, Arkansas and Indiana for the first-ever work requirements in Medicaid, and other states, including Kansas, have expressed interest in following suit.

The researchers sought to assess views about new Medicaid approaches in three Midwestern states with different policies: Ohio, which has a traditional Medicaid expansion without premiums and with minimal cost-sharing; Indiana, which expanded Medicaid coverage in 2015 but requires enrollees to pay premiums and contribute to health savings accounts; and Kansas, which did not expand Medicaid and where only very poor parents and disabled adults are eligible.

The study found that in 2017, health insurance coverage rates were significantly higher in the Medicaid expansion states of Ohio and Indiana than in the non-expansion state of Kansas.

Cost-related barriers to care were more common in Indiana than in Ohio. Indiana's health savings accounts were confusing for many enrollees, with nearly 40 percent saying they had never even heard of the required accounts and only 36 percent making regular required payments -- meaning that two-thirds of beneficiaries were at risk of losing benefits or coverage for non-payment.

In Kansas, 77 percent of low-income patients said they supported Medicaid expansion. Although Kansas is considering work requirements for its Medicaid program, most potential enrollees in the state were either already working or had a disability that prevented them from working. Only 11 percent of potential enrollees said they would be more likely to seek work if required to do so by Medicaid.

Work requirements and health savings accounts may work as intended for most beneficiaries, at least those who understand the incentives, the study said. But there's also a risk of more low-income patients being negatively impacted because they don't understand the new policies or can't afford them -- which suggests there should be ongoing, independent monitoring of these approaches.

Many in the medical community oppose work requirements. A major reason is that hospitals may find themselves dealing with more uninsured patients with chronic conditions. This spring, groups such as the American Academy of Family Physicians and the American Psychiatric Association said the policies would create considerable health risks and financial harm among vulnerable populations, and be at odds with efforts to address some of the country's biggest public health issues, like the opioid crisis.

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com

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