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Some fear impact as Oklahoma seeks Medicaid work requirement

[Thinkstock images]
[Thinkstock images]

Oklahoma City — A small slice of Oklahoma parents covered by Medicaid may have to be very careful with their time starting in February.

Work fewer than 80 hours per month, and they would lose eligibility under the work requirement the state is seeking from the federal Centers for Medicare and Medicaid Services.

But if they have only one child, and work more than 87 hours in a month, they could lose coverage too — because they'll be too wealthy to qualify for SoonerCare, Oklahoma's Medicaid program, even if they only earned minimum wage. The cutoff for adults who aren't pregnant and don't have a disability in Oklahoma is 46 percent of the federal poverty line, or $7,572 for a two-person family.

The Oklahoma Health Care Authority will submit its application to add a work requirement for some adults with coverage through SoonerCare in October. The public can comment on the proposal through Sept. 3 at or by calling 405-522-7914.

If the feds sign off, the state could roll out the policy on Feb. 1. SoonerCare recipients between the ages of 19 and 50 would have 90 days to start logging their hours and prove eligibility. They would be required to show an average of at least 20 hours per week of paid or unpaid work, or job training.

Pregnant women are exempt, as are those who gave birth in the last 60 days. Exemptions also are available for people certified as medically unable to work; caregivers for children under 6 or a person who is “physically incapacitated;” students in college or job training; patients in addiction treatment programs; and members of American Indian tribes.

The health care authority estimates about 6,000 of the 102,000 people between ages 19 and 50 who are enrolled in SoonerCare would fall under the work requirement. Recipients who fail to meet the criteria will be suspended for one month, and then allowed back only after they comply with the work requirement.

Carly Putnam, policy director at the left-leaning Oklahoma Policy Institute, said on a press call Tuesday that she thinks the exemptions are meant to pass over the most vulnerable people, but it isn't clear if they will succeed.

Most people on Soonercare would get low-wage jobs, which typically don't provide insurance and have irregular hours, creating child-care problems, Putnam said. Rural recipients have the added challenges of limited access to jobs, particularly if they don't have reliable transportation, she said.

“This becomes a cruel, inefficient system that will not make Oklahoma healthier or get more people to work,” she said. “For people who aren't working, getting health insurance helps them to get a job.”

Jonathan Small, president of the right-leaning Oklahoma Council of Public Affairs, said he thinks the opposition to work requirements is overstating the difficulties. Jobs are plentiful, he said, and almost all employers offer health insurance.

“In Oklahoma and across the country, demand for labor at all skill levels is the highest it's ever been,” he said. “Most people, as they begin working and they achieve on-the-job skills, employer-sponsored plans are one of the benefits that come with that.”

About 97 percent of employers with more than 50 workers in Oklahoma offer health benefits, but only 46 percent of those with fewer than 50 workers do, according to the Agency for Health Research and Quality. Some people who aren't offered insurance through work might be able to buy it through the exchange, but subsidies aren't available for people earning less than the poverty line ($16,460 for a family of two).

Small also pointed to data showing the average monthly income for low-skilled work nationwide was $2,090, or about $13 an hour working 40 hours a week. It isn't clear if Oklahoma workers would receive similar wages, however, since the national data includes states and cities with higher minimum wages.

The health care authority wrote in its application that the number of people using SoonerCare would likely fall, but attributed that to increased earnings.

“Oklahoma is committed to support SoonerCare members in improving their health outcomes and gaining independence through work training, meaningful employment, and helping others through volunteerism,” the waiver application said. “Meaningful work is part of building a healthy lifestyle and a contributing factor to self-esteem and overall well-being.”

A review of research on work and health, published by the Kaiser Family Foundation, found becoming unemployed tended to result in worse health, particularly mental health. It wasn't clear, however, that getting a job translated to better health. Part of the problem is that jobs vary greatly, and that healthy people are more likely to be working, which skews the results.

Less research exists on volunteering, and most has been done in people 50 and older. According to the Kaiser analysis, volunteers were less likely to report depression than non-volunteers, but volunteering more hours didn't appear to yield more benefits. It also found that volunteers who acted out of a desire to help others were more likely to report better mental health than those who volunteered to get some benefit for themselves — such as insurance eligibility.

Hurdles to clear

It's far from guaranteed that the state will get the waiver it seeks. Centers for Medicare signaled in January that it would be willing to consider Medicaid work requirements, so far it has granted permission to Kentucky, Indiana, Arkansas and New Hampshire. All those states have one thing in common, though: they expanded Medicaid under the Affordable Care Act, popularly known as Obamacare.

Oklahoma hasn't, and it isn't clear if the agency will approve a work requirement in a state with already strict limits. In Oklahoma's Medicaid program, called SoonerCare, most recipients are children or have disabilities. Healthy adults, who aren't pregnant and don't have children, aren't eligible, no matter how low their income.

So far, only Arkansas' requirement has taken effect, and the results aren't encouraging, said Joan Alker, director of the Georgetown University Center for Children and Families. About three-quarters of Arkansas recipients who were required to report their work hours or file for an exemption for the first time in June didn't do so, suggesting many didn't know they had to, she said. That could result in eligible people losing coverage.

Jo Stainsby, spokeswoman for the health care authority, said it hasn't finalized details on how to notify affected recipients, and is looking into how best to address barriers to work.

“The OHCA is currently conducting a series of both public and stakeholder meetings throughout the state. The agency is not only taking public comments concerning the waiver submission, but trying to build a support network throughout the state to assist these members with overcoming these obstacles,” she said.

While most children should remain eligible for SoonerCare, they still are at risk if their parents are left with medical debt, which could leave their families unable to pay rent and other bills, Alker said. Kids also will suffer if parents have to go without treatment for mental health conditions, she said.

Small points to the opposite — children benefiting from seeing their parents working.

“They get to see the things that make life more meaningful and healthy,” he said.

If patients lose access to SoonerCare, it will make it more difficult to get them in for primary care that can manage chronic conditions, said Dr. Nathan Valentine, chief medical officer at Variety Care. Even with a sliding scale, many people will either go without treatment or get behind on necessities like rent, he said.

“You're talking about adding a lot of bad and worse choices for mom,” he said. “Society pays for that with a higher level of costs.”

Dr. Jeff Reames, who oversees nine emergency rooms for Mercy Health Systems in Oklahoma, said the burden of caring for people who have lost SoonerCare coverage will fall disproportionately on rural hospitals. Data from the health care authority showed more than one-third of the affected people are in Oklahoma or Tulsa counties, however, and more than half the states' counties have 40 or fewer affected people within their borders.

People who don't have insurance tend to use the emergency room for their health care, including issues that could be taken care of in a cheaper setting, Reames said. The result is expensive care and lack of follow-up, since patients may not be able to afford prescriptions or a visit to a primary care provider, he said.

Offering job training and assistance to families on Medicaid could make sense, Alker said, but a work requirement won't achieve those goals. It appears the Oklahoma proposal doesn't include any extra funding to assist families with job searching or hurdles like finding child care, she said.

“This is not a proposal that can be fixed. It should be dropped,” she said. “This is about reducing enrollment.”

Counties with most affected SoonerCare recipients

Oklahoma: 1,155

Tulsa: 1,094

Cleveland: 285

Comanche: 269

LeFlore: 182


Counties with the largest percentage of their SoonerCare recipients affected

Cimarron: 1.6 percent

Beaver: 1.6 percent

Cotton: 1.5 percent

Ellis: 1.3 percent

Greer: 1.3 percent

Source: Oklahoma Health Care Authority

Meg Wingerter

Meg Wingerter has covered health at The Oklahoman since July 2017. Previously, she lived in Topeka, Kansas, and worked at Kansas News Service and The Topeka Capital-Journal, where she earned awards for business coverage. She graduated from... Read more ›