Issue: Health

Alabama Arise submits comments in opposition to Alabama’s ‘flagrantly cruel’ Medicaid work requirement proposal

By Alabama Arise

Alabama’s proposed new Medicaid work requirement waiver would be costly, counterproductive, ineffective and harmful to thousands of families who live in deep poverty, Arise wrote in comments submitted to the Alabama Medicaid Agency on Thursday, March 22. Click the “Download” button to read the full comments.

About 1 million Alabamians – mostly children, seniors, people with disabilities, and pregnant women – have Medicaid coverage. Out of that population, the state’s waiver would target about 75,000 adults with extremely low incomes who qualify for Medicaid as parents or other caretaker relatives of children (POCR). Alabamians in this group are ineligible for Medicaid if their incomes exceed 18 percent of the federal poverty level (about $312 a month for a family of three).

Because Alabama has not expanded Medicaid, the state’s work requirement plan would create a “catch-22 that forces people into the coverage gap,” Arise wrote in its official comments. Parents who work just 10 hours a week at minimum wage earn too much to qualify for Medicaid. But the state’s proposal would require them to work between 20 to 35 hours a week. That would put those parents in a no-win situation: They would lose Medicaid coverage if they don’t work – and also if they do.

“Threatening loss of health care in an attempt to force work efforts, without providing the supports that would make those work attempts successful, is flagrantly cruel and will result in no outcome other than poorer, more desperate and less healthy Alabama families,” Arise’s comments concluded.

‘Flagrantly cruel’ Medicaid changes would mean ‘poorer, more desperate and less healthy Alabama families,’ Arise tells state officials

By Chris Sanders

Alabama’s proposed new Medicaid work requirement waiver would be costly, counterproductive, ineffective and harmful to thousands of families who live in deep poverty, Arise Citizens’ Policy Project wrote in official comments submitted to state Medicaid officials on Thursday, March 22, 2018.

“Threatening loss of health care in an attempt to force work efforts, without providing the supports that would make those work attempts successful, is flagrantly cruel and will result in no outcome other than poorer, more desperate and less healthy Alabama families,” Arise’s comments concluded.

Medicaid covers about 1 million Alabamians. Of that total, the waiver would target 7.5 percent of them – about 75,000 adults with extremely low incomes who qualify for Medicaid as parents or other caretaker relatives of children. Alabamians in this group are ineligible for Medicaid if their incomes exceed 18 percent of the federal poverty level (about $312 a month for a family of three).

Because Alabama has not expanded Medicaid to cover adults with incomes below the poverty level, the state’s work requirement plan would create a “catch-22 that forces people into the coverage gap,” Arise wrote. About 300,000 Alabamians already are caught in the coverage gap, earning too much for Medicaid but too little to qualify for federal subsidies for Marketplace plans.

Parents who work just 10 hours a week at minimum wage earn too much to qualify for Medicaid. But the state’s proposal would require them to engage in work-related activities between 20 to 35 hours a week. That would leave thousands of Alabama parents in a no-win situation: They would lose their Medicaid coverage if they don’t work – and also if they do. Virtually all of them would end up uninsured, without access to employer-provided coverage or an affordable private plan.

Alabama’s proposal does not project the state’s cost to track Medicaid enrollees’ work activities and exemptions. It also does not identify whether or how the state would invest in child care, job training, transportation and other supports that low-income parents need to get and keep work.

Arise’s full comments on Alabama’s proposed Medicaid work requirement waiver are available here.

Education budget, landlord-tenant changes, HIV drug bill advance in Alabama Legislature

By Chris Sanders

K-12 teachers in Alabama wouldn’t get a raise next year under the Education Trust Fund (ETF) budget that a House committee approved Wednesday. The House is expected to vote on the plan next week.

The committee’s $5.9 billion budget would restore $10 million of state funding for Alabama State University that the Senate had removed. It also would include slight increases for K-12 and higher education, though next year’s ETF funding still would not come close to pre-recession levels. Check out AL.com’s report for more details.

Landlord-tenant revisions move closer to becoming law

Bills that would adjust several parts of Alabama’s landlord-tenant law in property owners’ favor are on the move in the Legislature. Without debate, the House voted 98-0 Tuesday for HB 523, sponsored by Rep. Paul Beckman, R-Prattville. A day later, a House committee approved SB 291, sponsored by Senate President Pro Tem Del Marsh, R-Anniston.

Both proposals would give landlords more time to refund a security deposit or give notice of why they are keeping some or all of it. The bills would increase that window from 35 days to 60 days. The measures also would allow landlords to treat a property as abandoned if electrical service is cut off for at least a week. In addition, landlords would have to provide only a seven-day written notice if they plan to terminate the lease for a violation that does not involve failure to pay rent. That would be down from the current 14-day timetable.

The only difference between the bills involves renters’ right to correct problems cited as a lease violation without getting the landlord’s written consent. SB 291 would give renters four chances every 12 months to correct such problems, while HB 523 would provide only two chances every 12 months.

Senate panel OKs bill to allow redistribution of some unopened HIV drugs

Pharmacies that dispense HIV medications for or in HIV clinics could redistribute certain unopened drugs under a bill that the Senate Health Committee approved Wednesday. SB 437, sponsored by Sen. Linda Coleman, D-Birmingham, moves to the Senate. A nearly identical House bill – HB 138, sponsored by Rep. Patricia Todd, D-Birmingham – passed the House 99-0 last week and awaits the Senate committee’s consideration.

HIV clinics now must destroy unopened medications if patients do not show up for treatment. HB 138 and SB 437 would allow pharmacies to dispense those drugs to other patients and would set controls on handling and oversight of the drugs. Arise and other consumer advocates last year urged Gov. Robert Bentley to support this policy change as his Medicaid Pharmacy Study Commission met to look at ways to reduce costs in the state’s Medicaid drug assistance programs.

Lawmakers will return Tuesday for the 25th of 30 allowable meeting days during the 2014 regular session, which is expected to last until early April.

By Chris Sanders, communications director. Posted March 14, 2014.

‘Simply cruel’: Testimony from Alabama Arise’s Carol Gundlach against Alabama’s Medicaid work requirements plan

By Carol Gundlach

Arise policy analyst Carol Gundlach testified against Alabama’s proposed Medicaid work requirements waiver during a public forum on Monday, March 5, 2018, in Montgomery. Here is the full text of Gundlach’s prepared remarks:

It is important for us to recognize that the people who will be affected by this proposed policy are exclusively the parents or guardians of children, often very young children. Over 90 percent of them are women. They are among the poorest people in Alabama, with an average monthly income of less than $400 for a family of three. These poor families are an extraordinarily vulnerable population to target for the potential loss of health care assistance.

Alabama offers few supports for people transitioning to work. While the waiver request says that people will be referred to supportive services, there is no reason to expect that they will be able to actually receive these services. Subsidized child care, in particular, is a necessity for a parent who works.

In Alabama, however, subsidized child care receives no state funding. As a result, most subsidized child care subsidies serve the highest priority categories, including foster children, children receiving protective services, and children who are in families that receive TANF (Temporary Assistance for Needy Families). In September 2017, there was a waiting list of over 1,000 children and significantly more pent-up need for subsidized day care. The same could be said for other support services, including job training and public transportation, which are essential job supports.

The waiver request says that people who can’t find services like transportation or child care will be exempt. But the way this section is written is particularly confusing and unclear. The waiver request says people “compliant with JOBS are exempt.” And it says that anyone exempt or deferred from JOBS (Job Opportunities and Basic Skills) will not be required to engage in work activities. To be either participating or exempt from JOBS, though, one must be receiving TANF.

There are around 4,000 adults receiving TANF and 75,000 people in the POCR (Parents and Other Caretaker Relatives) Medicaid capacity. While it appears to be implied, the actual language of the waiver request is silent or whether any of the other 71,000 participants not receiving TANF will be deferred if they don’t have child care or transportation.

The waiver request says the Medicaid work program would be “modeled” on the JOBS program. And the proposed memorandum of understanding with DHR (the Department of Human Resources) seems to indicate that non-deferred POCRs will actually be enrolled in the JOBS program or another program administered by DHR that is very similar to JOBS.

A critical element of the JOBS program is access to emergency and job support services, including auto repair, emergency housing assistance, transportation assistance, uniforms and other needs. One of the most important supports in the JOBS program is priority access to subsidized child care without having to be placed on a waiting list.

Will POCR recipients also become eligible for these TANF/JOBS-funded services? And if so, would those auxiliary services by paid for with the already inadequate TANF block grant? If so, this waiver proposes to try to expand services now covering 3,700 people to an estimated additional 17,000 individuals, further stressing an already underfunded JOBS program and reducing assistance now reserved for TANF participants mandated to participate in JOBS.

The waiver request says “every adult in the household” would be required to participate. If this is the case, is the plan to terminate the Medicaid of a compliant or exempt Medicaid recipient if a non-recipient who lives in the same household doesn’t participate? Besides the deep unfairness of punishing the Medicaid recipient for the behavior of another household member, this policy empowers the non-recipient to use the threat of the loss of insurance to abuse and control the Medicaid recipient.

Ultimately, this waiver request raises more questions about what is being proposed than it answers. Most of the answers will apparently be found in the yet unspecified MOUs with the Department of Human Resources and the Department of Labor – MOUs that may not be available to the public before they are implemented.

We need not to overlook that the intent of this proposal is to take health insurance away from targeted women who are unable, for whatever reason, to comply with employment and training activities. The request speaks to the benefits of work for children and families, and we certainly agree that, with the right supports, families are better off when there is earned income.

But I cannot see how the loss of parental health insurance can possibly benefit children. If Mom cannot afford her asthma medicine or her insulin because her Medicaid has been discontinued, then she gets sick and can’t work, or ends up in the hospital, or doesn’t buy the food, clothing or other necessities for her children in order to buy the medicine she needs. Any of these outcomes will hurt the family and the children.

The dignity of work, and the income it produces, does of course benefit families. But to use health care as the stick to force work efforts, without providing the supports that make work attempts successful, is simply cruel and will result in no outcome other than poorer, more desperate and less healthy Alabama families.

‘Alabama’s new catch-22’: Testimony from Alabama Arise’s Kimble Forrister against Alabama’s Medicaid work requirement plan

By Kimble Forrister

Arise executive director Kimble Forrister testified against Alabama’s proposed Medicaid work requirements waiver during a public forum on Monday, March 5, 2018, in Montgomery. Here is the full text of Forrister’s prepared remarks:

When we compare Medicaid’s waiver proposal to DHR’s welfare reform proposal in 1996, what’s most striking is Medicaid’s lack of data. How can we analyze the target population when Medicaid can’t give us information on the adults in the POCR (Parents and Other Caretaker Relatives) population?

I learned a lot when I served on Gov. Fob James’ Welfare Reform Commission. First, we analyzed Gov. James’ unjustified claims that the AFDC program (that was Aid to Families with Dependent Children, the cash welfare program now called TANF) incentivized teen pregnancy, and that AFDC was a budget-buster. In fact, it just didn’t make sense that any woman on welfare would get pregnant just to gain an additional $29 a month in welfare benefits. And with cash welfare amounting to one-half of 1 percent of the General Fund budget, it was hardly a budget-buster.

Again today, we hear unjustified claims from our governor. Gov. Kay Ivey says she wants to save taxpayer dollars and reserve Medicaid for the people who need it most. But who needs Medicaid more than the mother who’s trying to support two kids on $312 a month or less?

Even the woman who works 10 hours a week at minimum wage makes too much to meet this standard. And if this new policy “succeeds,” and she gets a 20-hour-a-week job, she is no longer eligible for Medicaid – and that defeats the whole purpose. Her new low-wage job is unlikely to provide health coverage. Her income is unlikely to be high enough to allow her to buy coverage on the marketplace. She will be caught in Alabama’s new catch-22.

Changes like this can be game-changers – but they can change the game in a bad way. We learned it the hard way in the 1990s. Well-meaning professionals in the Family Assistance section of DHR (the Department of Human Resources) assured us that there were three kinds of people among the 26,600 adult recipients (note that this was about a third of the POCR population):

  • There were those who were only using cash welfare as a temporary program that would help them get back on their feet, and they would be back in the workforce in a three to six months. They had data to show that this was a large share of the caseload. And apparently today’s Medicaid Agency is unable to do a similar analysis of the POCR caseload.
  • At the other end of the spectrum were the hardship cases who faced extreme barriers to employment, and the professionals assured us that they would be protected from harsh consequences. They truly needed the program. We would think that these are among the 4,000 to 5,000 adults now on TANF, about a sixth of the original population.
  • The professionals assured us that a middle group – between the job-ready at one end and the hardship cases at the other – were the people who just needed a kick in the pants to get off welfare and into a job, any job, and that it was easier to move up the ladder from any job than from no job.

This analysis makes some sense, but only in the context of an understanding of the barriers: women on welfare consistently said that in order to enter the workforce, they needed four things: jobs, child care, transportation and health care.

DHR in fact made some effort in these areas. People could count on a year of Medicaid coverage and child care when they took a job, and they even got a few months of cash welfare to ease the transition to work.

But we analyzed the data from the first year of implementation and discovered that the numbers didn’t match the theory. An economist on our staff did a regression analysis and discovered that the numbers in the caseload did not line up with the numbers moving from welfare to work. Instead, the lower caseload numbers lined up with the lower number coming in the front door, not the number leaving for employment.

The reality was, these women could not overcome the challenges of child care and transportation to even go to the job interviews that were required before they could get TANF benefits. The theory – that a kick in the pants would lead to a job – did not explain the numbers. The reality, played out for thousands of women across the state, was that some our most vulnerable people – young mothers who can’t access child care and transportation – were denied the $50 a week we provide in TANF benefits.

We would urge the Alabama Medicaid Agency to take a hard look at its theories and compare the theories to the numbers. Are you actually cycling a significant number of cases through a transitional period of difficulty between jobs? If so, you probably don’t need a big increase in administrative costs to get them to work.

Medicaid’s own projections show that some 57,000 people in the POCR caseload will be exempted from work requirements. But the administrative cost of making that determination will add significantly to our famously low-overhead Medicaid budget. It won’t be so low-overhead anymore.

The group that’s left – perhaps 17,000 people who are not job-ready and not hardship cases – is the group that’s at risk of essentially being kicked while they’re down. If you can’t arrange child care and transportation to start on the path to a job, you’re not getting help. You’re getting the front door slammed in your face.

Bottom line: In a state with 18.5 percent of its people in poverty, this plan proposes to put about 1.5 percent of its people under a microscope, expecting to find about 1/3 of a percent they can move off Medicaid. Gov. Ivey is proposing to put a huge administrative effort into forcing this 1/3 of a percent of the population into jobs, with the result that a few thousand mothers might get jobs, but they surely will no longer have health care.

If Alabama seriously wants to test its ability to move people from POCR to the workforce, why not propose a one-year pilot program that offers work supports without the penalties that remove their health care?

Alabama mothers, children bear brunt of proposed new Medicaid restrictions

By Chris Sanders

Alabama’s bid to impose a work requirement on parents receiving Medicaid could cost as many as 8,700 people their health coverage in the first year, mainly affecting mothers whose children also would feel the impact, according to a new analysis by the Georgetown University Center for Children and Families (CCF) and Arise Citizens’ Policy Project (ACPP).

The proposal would create a Catch-22 for these families who already live well below the poverty line: Any parent working the 20 to 35 hours required under the state proposal would make too much money to qualify for Medicaid – but likely not enough to afford private insurance. These harsh new restrictions would disproportionately hurt families living in Alabama’s rural communities and small towns where jobs are scarce.

“Alabama’s proposal creates more barriers to Medicaid coverage and will not help families rise out of poverty. In fact, the opposite is true – many parents and children are likely to lose health coverage, which exposes them to greater financial instability,” said Joan Alker, director of the Georgetown University research center. “It’s hard enough to raise a family on such a limited income without someone putting more roadblocks in the way.”

Alabama is not the first state to seek a work requirement, but it is one of the first to do so without accepting federal funding to expand Medicaid to adults with incomes slightly above the poverty line (138 percent of the federal poverty level). Around 300,000 Alabamians are caught in the coverage gap, earning too much to qualify for Medicaid but too little to qualify for subsidies for marketplace coverage through the Affordable Care Act.

In Alabama, only the poorest parents and caregivers, those making 18 percent of the poverty level or less – $3,740 a year for a family of three, or about $312 a month – now qualify for Medicaid. That is the strictest eligibility requirement in the nation (along with Texas). Because Alabama has not expanded Medicaid, the work requirement would apply only to parents with extremely low incomes.

The analysis found that among this population:
•    More than 85 percent are women.
•    60 percent are not in the workforce, in many cases because they are caring for someone else or have an illness or disability; 24 percent describe themselves as unemployed. The remainder are already reporting some work.
•    58 percent are African American; 40 percent are white.
•    35 percent are young parents under age 30.

A proposal for a Medicaid work requirement, now undergoing a state public comment period before submission to the federal government, could prove disastrous for many Alabama families, ACPP policy director Jim Carnes said.

“The goal of this cruel, counterproductive plan is to take health insurance away from thousands of Alabamians who are living in desperate poverty,” Carnes said. “By creating barriers to coverage rather than promoting it, Alabama’s work requirement fails the most fundamental test for Medicaid policy changes.”

Alabama’s proposal also seeks to trim eligibility for Transitional Medical Assistance – despite the fact that TMA is designed specifically to provide stability in health coverage for families whose incomes are increasing because they are working more.

In addition, the proposal could fuel an increase in the number of Alabama children without health coverage, according to the report, because uninsured parents are more likely to have uninsured children. Alabama’s rate of uninsured children – just 2.4 percent – is the lowest in the South. Overall, children and families in Alabama’s rural communities and small towns are more likely to use Medicaid coverage to meet their health care needs than those in metropolitan areas, a 2017 Georgetown University CCF/University of North Carolina study showed.

“As a pediatrician practicing in rural Alabama for 37 years, I have seen firsthand what happens when parents cannot access health care: Their children’s health suffers,” said Dr. Marsha Raulerson, who is a pediatrician in Brewton and a member of the American Academy of Pediatrics. “If approved, the Alabama Medicaid work requirement would be a step backwards for a state that has been a national leader in covering children.”

The impact of Alabama’s proposed Medicaid work requirement on low-income families with children

By Alabama Arise

Alabama is seeking federal permission through a Section 1115 Medicaid demonstration waiver to require parents and caregivers who rely on Medicaid to work 20 to 35 hours a week, prove they are looking or training for a job or do community service before receiving Medicaid. This proposal targets the very poorest and most vulnerable families with children in Alabama – many of whom will lose their health coverage, according to a new report by Arise Citizens’ Policy Project and the Georgetown University Center for Children and Families.

Alabama’s proposed work requirement and subsequent coverage losses would disproportionately affect mothers, African Americans and families living in rural communities. Many of these women will likely become uninsured, as employer-sponsored insurance for low-wage workers is sparse.

The proposal creates a Catch-22: Any parent working the 20 to 35 hours required would make too much money to qualify for Medicaid — but likely not enough to afford private insurance. An analysis of the state’s estimates finds that 8,700 parents would be removed from Medicaid in the first year alone. When their parents lose health coverage, children suffer. The families face increased debt, and children are less likely to visit the doctor regularly and more likely to become uninsured themselves. Children in these families are already disproportionately uninsured.

White House’s proposed cuts to nutrition, health care and housing would hurt struggling Alabamians

By Chris Sanders

Arise Citizens’ Policy Project executive director Kimble Forrister issued the following statement Tuesday, Feb. 13, 2018, in response to the release of the White House’s proposed 2019 federal budget:

“The White House’s budget proposal lays out a vision of a dark and troubling future for struggling families across Alabama. This plan would slash services like nutrition assistance, health care and affordable housing, making it even tougher for hard-working Alabamians struggling to make ends meet. Life would become harder for everyday families, even as big corporations and wealthy people would continue to enjoy the huge federal tax cuts that were just enacted.

“This budget plan would cut more than $200 billion over the next decade from SNAP assistance, which helps one in five Alabama families put food on the table. It would cost Alabama more than $140 million in federal funding for affordable housing next year, even as the state faces a shortage of more than 76,000 affordable and available homes for households with extremely low incomes. And it would cut hundreds of billions of dollars by 2028 from Medicaid, which provides health coverage for one in five Alabamians – almost all of whom are children, seniors, pregnant women, or people with disabilities.

“Public policies should make it easier, not harder, for working families to get ahead. This budget is a wake-up call about the legislative goals and values of this administration. It paints a bleak picture for our country’s future, and we can’t afford to allow that vision to become a reality. Alabama’s members of Congress should reject this misguided agenda and instead work to ensure that families have the resources and opportunities they need to reach their full potential.”

New Medicaid hurdles would create barriers to health in Alabama

By Alabama Arise

The Trump administration is encouraging states to impose work requirements on “non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability.” State Medicaid Commissioner Stephanie Azar told lawmakers the agency likely will seek approval for such a requirement this year. SB 140, sponsored by Sen. Arthur Orr, R-Decatur, and HB 331, sponsored by Rep. Arnold Mooney, R-Birmingham, would mandate this policy and place other statutory conditions on Medicaid eligibility. The bill would:

  • Require Alabama Medicaid to “request approval of the firmest but nonetheless most reasonable work requirements allowed” by the federal government.
  • Require semi-annual, rather than annual, eligibility verification for Medicaid beneficiaries, including a review of financial resources.

Unlike Alabama, most states seeking to impose work requirements have expanded Medicaid to cover low-income working adults. Most of Alabama’s Medicaid beneficiaries are children in low-income families. The next largest groups are people with disabilities, low-income seniors and pregnant women. Only about 75,000 parents and other caretaker relatives of Medicaid children qualify for Medicaid coverage. Nearly 90 percent of them are women. The income limit for Medicaid parents is just 18 percent of the federal poverty level ($307 per month for a family of three).

SB 140 and HB 331 leave many questions unanswered:

  • Given Alabama’s stringent Medicaid eligibility for adults, what group or groups will a work requirement target?
  • What training and work supports will Alabama offer to help affected beneficiaries find and keep jobs? For example, will the state’s wait-listed program for subsidized child care be expanded?
  • Given Alabama’s strong support for children’s health insurance, how will the state mitigate the harm that occurs to children when parents lose coverage?
  • How will the work requirement apply to parents who are in school? To those awaiting disability determination? To those who lack reliable transportation? To those who live in areas with high unemployment?
  • Is Medicaid equipped and funded to monitor compliance with the new requirements while making sure no individuals eligible for Medicaid fall through the new procedural cracks?
  • Since the Affordable Care Act ended asset tests for Medicaid, how does a semi-annual verification of “financial resources” comply?
  • If health coverage is a privilege for working people, why hasn’t Alabama expanded Medicaid to cover low-income workers who don’t get employer coverage and can’t afford private plans?

BOTTOM LINE: Creating work requirements and more eligibility hurdles for Alabama Medicaid would erect unreasonable barriers to health care. Making Alabama’s bare-bones Medicaid even more stringent is the wrong way to promote a healthier workforce.

Four reasons to oppose work requirements for Alabama Medicaid

By Chris Sanders

(1) The vast majority of enrollees are children or otherwise exempt. Medicaid covers about 1 million Alabamians (roughly one in every five people in the state), and most of them are children. Almost all of the rest are seniors, pregnant women, or people with disabilities who would be exempt from work requirements. Only about 7.5 percent of enrollees – roughly 75,000 people in the “parent and other caretaker relative” category – could be subject to a requirement.

(2) Many Alabamians who would face work requirements have serious barriers to employment. Nearly 90 percent of the 75,000 parents and caretakers covered by Alabama Medicaid are women. Many are going to school or caring for young children at home. Medicaid work requirements would not make child care, transportation or job training more accessible for them.

(3) Adults who lose Medicaid would fall into the coverage gap. Most states seeking to impose work requirements have expanded Medicaid for working-age adults. But Alabama hasn’t. About 300,000 Alabama adults are caught in a coverage gap. They earn too much for Medicaid but too little to receive subsidies for Marketplace coverage.

(4) Work requirements would create a catch-22 for people in poverty. Alabama parents can’t qualify for Medicaid if their income is above 18 percent of the poverty line. Someone working just 20 hours a week at minimum wage earns too much to qualify for Medicaid in Alabama. It’s unfair to require people to work to keep health coverage, only to take it away when they do.

By Chris Sanders, communications director, and Jim Carnes, policy director. Last updated Jan. 26, 2018.