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Florida's Medicaid Work Requirements Will Eliminate the Program for the Very Poor

A federal judge struck down work requirements in Arkansas and Kentucky, but Republican state legislatures continue to pursue them around the country.
A man dressed as Donald Trump at a Florida protest against the Senate's 2017 health-care bill, which proposed drastic Medicaid cuts.

A man dressed as Donald Trump at a Florida protest against the Senate's 2017 health-care bill, which proposed drastic Medicaid cuts.

At the end of April, the Florida House of Representatives voted 71–44, along party lines, to pass HB955, legislation that would result in the implementation of work requirements on all the state's non-disabled adult Medicaid recipients. Florida is home to some 500,000 recipients of Medicaid, the federal health-care program for the poor and disabled. Per the bill's proposal, those beneficiaries would be required to prove they are working or actively seeking jobs to maintain their eligibility, potentially jeopardizing some 100,000 people their current coverage. It represents the most aggressive proposed cuts to the Medicaid program to date.

Though Medicaid is a federal program, states can proposition for changes in their administration of funds and benefits. If approved by the state Senate, HB955 would authorize Governor Ron DeSantis to ask the federal Department of Health and Human Services for a Section 1115 waiver, granting permission to impose a new work requirement of 20 hours per week on adult Medicaid recipients who aren't disabled. But 20 hours of work at Florida's minimum wage of $8.46 per hour would yield about $677 per month, well above the state's income limit of 33 percent of federal poverty level for Medicaid eligibility, creating a bind that's all but certain to eliminate coverage for Florida's very poor either way. Though the bill didn't make it out of the Florida Senate before the end of session earlier this month, it's likely to be taken up again once the legislature reconvenes.

Florida isn't the only state to seek work requirements restricting access to Medicaid. Already, eight states have done the same. But Florida's proposal is by far the harshest of the bunch, and has sounded alarms for onlookers and advocacy groups.

Florida is unique in that it's the only state to propose Medicaid work requirements that refused to expand Medicaid under the Affordable Care Act. In expansion states, where the income qualifications were relaxed via the ACA, all adults are covered up to 138 percent of the poverty line. Not so in Florida, where the only adults with Medicaid eligibility are either disabled or very poor parents whose income falls below 33 percent of the federal poverty level.

That means that the work requirements are going to overwhelmingly target poor families—mostly single mothers making between $300 and $400 a month, according to Joan Alker, executive director of the Center for Children and Families and a research professor at the Georgetown McCourt School of Public Policy. The proposed reporting rules create a catch-22 for parents, who can choose between losing coverage by not working or disqualifying themselves by over-earning. Without any provision for childcare, those hours worked may not even result in any increase in take-home pay. The result would be the functional elimination of the Medicaid program for Florida's very poor.

"This is the most radical way for this policy I've seen," Alker says.

"Florida Republicans ought to be ashamed of themselves with their latest move to gut Medicaid by instituting brutal so-called 'work requirements' on people who so desperately need access to health care," said Protect Our Care Executive Director Brad Woodhouse in a statement ahead of the House's late April vote. "Republicans in Florida—goaded by President [Donald] Trump—are more determined than ever to enact these draconian laws, putting in harm's way the health care of over 100,000 Floridians."

After the summary failure of 2017 push by Republicans in United States Congress to repeal the Affordable Care Act and levy major cuts to Medicaid and Medicare, the Trump administration trained its efforts on the Medicaid waiver policy as a way to advance its policy goals. Once the congressional route to cutting Medicaid—the country's largest health insurance program that accounts for $1 out of every $6 spent on health care in the U.S.—proved inhospitable, the administration encouraged states to propose such cuts on their own. They've gotten a boost from conservative groups like the Koch-funded Foundation for Government Accountability, which has lobbied for such proposals in state legislatures. And those Republican-controlled states have been happy to oblige, with Alabama, Oklahoma, South Carolina, and others submitting waiver requests in order to implement work requirements.

Implementation, however, has proven more challenging. The Trump administration approved work requirements in Arkansas and Kentucky, only to see those programs dashed resoundingly by federal district judge James Boasberg at the end of March, who pointed to onerous reporting requirements and a lack of planning by states to deal with the startling amount of lost coverage. Citing those states' failure to consider just how many people would lose their health coverage, Boasberg described the approval of such programs as "arbitrary and capricious," and insisted that work requirements be halted immediately.

In Arkansas, which was the first state to implement such mandates, the impacts vested almost immediately. The state saw roughly 20,000 purged from their health coverage in just a handful of months after implementation in 2018, and a coverage loss rate of 23 percent. Only 11 percent of those who lost coverage due to work requirements went on to regain it. All this despite the fact that Arkansas exempted all parents from reporting requirements.

There was some hope that the district court's ruling would prove to be a major setback in the work requirement campaign. But Florida's legislation shows that Republicans remained undeterred. If anything, this newest set of proposals is more brazen than anything yet seen.

Advocates at conservative groups like the Heartland Institute have claimed that Medicaid cuts are necessary to combat rising costs associated with the program, and save benefits for those who truly need them. But the federal government fronts more than 60 percent of Medicaid costs, and very poor families are exactly who the program was designed to aid.

There are other reasons, too, to be concerned about Medicaid cuts. It's very rare to see an uninsured parent with an insured child, which means that children may miss out on necessary medical care for fear of the exorbitant medical costs without coverage. Uninsured parents are subject to medical debt and bankruptcy, and that burden can be easily transferred to the children themselves. "Maternal depression is very, very high in women living in poverty, and that is a huge barrier for a primary caregiver," Alker notes.

Despite those risks, it's clear that state-level Medicaid work requirements will persist. North Carolina is currently considering a bill of its own, while Alaska and Utah have begun to explore waiver programs, and, with the encouragement of the White House, there's no reason to expect the trend to stop in Republican legislatures. But it's the Florida bill, with its extreme breadth in cuts, that will prove defining. "We're at a moment where, if the Trump administration will approve one of these in a non-expansion state," Alker says, "that's a huge, huge moment."