South Carolina adults who qualify for low-income Medicaid coverage may need to prove later this year they have a job or risk losing their health benefits.
Gov. Henry McMaster's Medicaid agency is officially pursuing the rule change more than a year after President Donald Trump's administration announced it would support Medicaid work requirements.
But experts argue in a new report the plan will mainly harm mothers and, inadvertently, their children, who are more likely to lack health insurance if their parents are uninsured.
Black women in rural areas would be hit hardest, the report's authors anticipate. The paper was published Friday by the Georgetown University Center for Children and Families and the S.C. Appleseed Legal Justice Center.
"We’re only talking about parents here. That’s it," said Joan Alker, executive director of the Georgetown group. "These are very vulnerable families."
Unlike the federal Medicare program, which covers seniors and younger adults with disabilities, states are given some latitude to craft their own Medicaid rules because the low-income health insurance program is financed with both state and federal money.
Even so, states like South Carolina that want to impose Medicaid work requirements or implement other significant changes to Medicaid eligibility must apply for a federal waiver before moving forward.
South Carolina now finds itself in the middle of that application process. If approved, most adults on Medicaid in this state will be required to show they work at least 80 hours a month. Exemptions will be granted to full-time caregivers and other categories of adults.
The stated goal of the proposal is to improve health by boosting employment. The public has an opportunity to submit comments about the plan until Jan. 22.
Sue Berkowitz, executive director of the S.C. Appleseed Legal Justice Center, opposes the proposal. She argues it does not address significant barriers to employment, including transportation, the cost of child care or the scarcity of jobs in rural areas.
On Friday, she accused the state Medicaid agency of launching the public comment period in early December to limit the number of entries submitted over the holiday season.
"It was not done by accident, but actually done on purpose," said Berkowitz, a member of the Medicaid agency's Medical Care Advisory Committee.
A spokeswoman for the state Medicaid agency said Friday the agency has made its intention to pursue work requirements public for many months.
"While federal requirements would have allowed the agency to close the public comment period on Jan. 2, 2019, the agency extended the period to Jan. 22 to provide the public an opportunity to comment for several weeks after the Christmas and New Year’s holidays," Medicaid spokeswoman Colleen Mullis said in a prepared statement.
Meanwhile, similar proposals to institute Medicaid work requirements in other states have drawn significant criticism. In this state alone, Medicaid covers more than 1 million people and work requirements could potentially kick thousands of adults out of the program. But so far, S.C. Medicaid Director Joshua Baker said in late December his department has fielded little feedback — good or bad.
In fact, it's been a month since the S.C. Department of Health and Human Services opened up the work requirements proposal for public comment and so far the agency has only received two written statements.
"I’ve not seen, by and large, a lot of public participation," Baker said.
Alker, with Georgetown University, called the number comments submitted so far in South Carolina "extremely low."
"Two is not a good number," she said.
By comparison, 11,000 public comments were submitted last year when Kentucky proposed implementing Medicaid work requirements, she said.
The holidays may have had something to do with public participation in South Carolina, Baker acknowledged.
He also speculated that the reason participation has been low is related to South Carolina's existing rules. Medicaid eligibility for South Carolina adults is already strict compared with other states and the agency anticipates relatively few beneficiaries here will be impacted by the work requirements if they take effect in 2019.
Within five years, Baker's department predicts as many as 5,000 adults may be considered non-compliant — a small percentage of total enrollment.
But experts at Georgetown University and the Appleseed Legal Justice Center believe that number is too low. They estimate in the new report as many as 26,000 people may lose coverage within five years if the new rules are implemented.
In Arkansas, where state officials launched Medicaid work requirements last year, an estimated 17,000 adults have lost coverage, Alker said. Many of them may actually comply with the new rules, she said, but were tripped up by bureaucratic red tape.
"The policy is clearly failing to achieve it’s purported goal of supporting work," Alker said.
In 2017, when the Trump administration announced its intention to support Medicaid work requirements, the idea wasn't brand new. Families that receive other forms of government assistance, such as food stamps, are already required to prove that they're employed or looking for work.
“These are individuals who are physically capable of being actively engaged in their communities, whether it be through working, volunteering, going to school or obtaining job training,” said Seema Verma, director of the federal Centers for Medicare & Medicaid Services, in 2017. “Let me be clear to everyone in this room: We will approve proposals that promote community engagement activities.”
Though the announcement was met with mixed reactions, a number of states decided to move forward with their own proposals.
McMaster was an early advocate for the idea. Twelve months ago, he officially announced South Carolina would pursue a work requirements waiver, arguing "we should always endeavor to help South Carolinians in need find their path to gainful employment and away from the temporary assistance of government."
Steve Skardon, executive director of the nonprofit Palmetto Project, said he thinks it would be wiser for South Carolina to watch how Medicaid work requirements play out in other parts of the country.
"There are already other states that are doing demonstration projects just like this," Skardon said. "Why are we doing the same thing? ... It just looks like they’re trying to lob people off the rolls. We hope that’s not the case in South Carolina, obviously, but that could happen very easily."
The Palmetto Project has not officially submitted a public comment about the proposal, Shardon said, but the group intends to before the Jan. 22 deadline.
On Friday, the state Medicaid agency announced it will hold two more meetings about the proposed work requirements to allow the public more opportunities to weigh in. Meetings held in December were poorly attended.
All of the public comments will be submitted with the state's official application to the Centers for Medicare & Medicaid Services. The federal government will open up another 30-day public comment period related to the proposal later this year, Baker explained.
He did not know how long the federal government will take to render a final decision. Negotiations could take several months, or longer.
It's not guaranteed that the plan will be approved. South Carolina is one of 14 states that has not adopted Medicaid expansion under the Affordable Care Act and, to date, the federal government has not approved work requirements in any of those non-expansion states, Alker said.