NC lawmakers push Medicaid work requirements as patients, advocates and courts push back

By: - April 4, 2019 5:08 am
Emily Henderson was kicked off Medicaid when she got a $2 per hour raise last year. Her son, who has diabetes, remains covered, but proposed work requirements in North Carolina could put that at risk. (Photo by Steven Whitsitt)

Emily Henderson was kicked off of Medicaid last year when she went from making $8 per hour at her job to $10 per hour. The raise put her over the income limit. Her son, who is diabetic, remains covered, but she has to choose more often than not between paying to take care of her own health without insurance coverage and paying her bills.

Her story of losing coverage is one that could become a reality for many more people if Republican lawmakers in the North Carolina General Assembly pass a bill to implement work reporting requirements for “able-bodied” adults who receive Medicaid health benefits.

The current income limits are “already making it difficult,” Henderson said. “They’re handcuffing people to poverty to maintain healthcare,” she continued.

Senate Bill 387 would require current North Carolina Medicaid recipients to work or perform community service for a certain number of hours per week to retain their benefits. The introduction of the measure came within hours of a federal judge striking down similar requirements in Arkansas and Kentucky because they ran afoul of the assistance program’s overall objective.

Adam Searing

“The [federal] cases should give any state pause for moving forward with work requirements,” said Adam Searing, associate professor of the practice at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.

North Carolina’s bill is considered significantly more extreme than the ones in Arkansas and Kentucky – and even if passed, would require approval from the Trump Administration – because it would apply to the current Medicaid population, instead of an expanded population.

The Trump Administration has yet to approve a work requirements waiver that applies to a traditional Medicaid program. If such a waiver was implemented in North Carolina, Searing said it would disproportionately impact “really, really poor parents” of children older than one year, because there are exceptions for other populations receiving care, including children themselves, the elderly and the blind.

“That is a real nasty, nasty addition to Medicaid,” Searing said of North Carolina legislation.

Once low-income parents start working more hours to meet work-reporting requirements, it’s possible they could make too much money to qualify for Medicaid, like Henderson. She wasn’t subjected to specific work reporting requirements, but once she got a raise, she made too much money to qualify for Medicaid.

Now Henderson, a mother of four, works more and makes more, but she’s still barely making ends meet, and without healthcare to boot.

“I have to choose sometimes between my medication, some of [my son’s] additional supplies or whether I’m going to pay a bill to keep things going,” she said. “I’m always trying to figure out, what am I going to do this month. It’s a challenge.”

There are 2.1 million low income North Carolinians who receive Medicaid benefits – about 1.2 million are children. Parent eligibility for Medicaid in North Carolina is $8,004.

Henderson said lawmakers don’t understand what it’s like to make a living on such a small amount of money, and until they do, change will be difficult.

“They need to walk a month or two in a typical mom or dad’s shows and see how they make it,” she said. “It’s going to take a dose of reality for them, but that reality will never come because they’re covered.”

In July of last year, Arkansas began requiring Medicaid expansion enrollees ages 30 to 49 to report each month about whether or not they engaged in 80 hours of work, or other qualifying activities, in order to receive coverage.

One result of the change was that 25 percent of the Arkansans who were subjected to the requirement lost coverage. Studies suggest only six percent of those individuals were failing to meet the work requirements – their issues were more administrative.

“The harm from (the work requirements) is just tremendous,” said Elizabeth Edwards, a staff attorney at the National Health Law Program.

North Carolinians gathered outside legislative leaders’ offices in February to advocate for Medicaid expansion. (Photo by Phyllis Nunn)

Individuals were becoming worse off because of the requirements. Edwards explained that Medicaid is different than food benefit programs, in which work requirements have been imposed. The federal statute outlining the objective of Medicaid is to provide people with health coverage, not to make sure they’re working.

“Under Medicaid, coverage matters,” Edwards said. “At the heart of it, quite simply, the work requirements are illegal and bad policy.”

There is still an appeal process, and Edwards said she can’t really predict what the Trump Administration will do in response to the federal court’s decision to strike down the work requirements.

“We certainly can be hopeful,” she added.

Christina Root is hoping that personal medical stories will help sway lawmakers to see things her way, both when it comes to the work requirements and when it comes to expanding Medicaid, which they’ve been resisting for years.

Lately, hearing lawmakers talk about forcing “able-bodied” Medicaid recipients to meet certain work requirements has been triggering for her. She was technically considered “able-bodied” while battling Stage 3 triple-negative breast cancer and surviving in the Medicaid coverage gap. But working was the last thing she could have done between chemotherapy, surgery. radiation and endless doctor appointments.

“If you need Medicaid, things aren’t going great to begin with,” she said, adding that the population of “able-bodied” recipients lawmakers are talking about are already struggling, often because of health problems. “We’re talking about people’s lives, and if people don’t get better, they can’t be productive members of society. I just think it puts way too much of a burden on people.”

Root said she thinks there is a stigma that people on Medicaid are lazy, and it’s just not true.

“Many single income cancer patients have to resort to Medicaid, because they got cancer and can’t work or work very limited, irregular hours,” she said. “So what they’re trying to do is have work requirements for people too sick to work. All to make sure there aren’t any ‘able-bodied’ people getting healthcare they haven’t earned?”

Issues with the reporting requirements for her healthcare plan caused her coverage to be cancelled several times, one time causing a delay in chemotherapy, she said.

“That broke me,” she said. “It hit me that bureaucracy could literally kill me.”

She said she is educated, has Internet access and considers herself to be a good researcher, but the bureaucracy she had to go through to try and get and keep insurance was a nightmare. She had to submit several tax forms, try to document irregular and future income, file several appeals and described the process involved with healthcare as cumbersome.

“The punishment for any error in reporting income into an inflexible web portal was to terminate my healthcare during cancer treatment,” she said. “That was the real battle I fought every day. I just feel like we can’t be a society that lets this happen to people. If it could break me, it could break anybody. And cancer didn’t break me, but this nearly did.”

Searing noted that if North Carolina passed a work requirements bill and the  Trump administration approved such a waiver, challenges would end up in the same court with the same judge who decided the Arkansas and Kentucky cases.

“There’s a great legal argument here,” he said. “This is just a veiled attempt to kick people off Medicaid.”

He added that “there’s just no question” the proposed work requirements would be challenged in court if implemented.

Editor’s note: This story has been updated to provide more details about Root’s experience.

Our stories may be republished online or in print under Creative Commons license CC BY-NC-ND 4.0. We ask that you edit only for style or to shorten, provide proper attribution and link to our web site. Please see our republishing guidelines for use of photos and graphics.