The Iowa Legislature gavels into session this week, and it’s anybody’s guess what issues will emerge as top priorities. However, it appears Republicans are interested in studying a work requirement for some people on Medicaid, the health insurance program for 600,000 Iowans.
Republican leaders in the Senate and House have expressed interest, with Senate Majority Leader Jack Whitver and House Speaker Linda Upmeyer both framing it as a workforce issue.
"We genuinely need people in the workforce. And if there’s a way to do that to where we can get people the skills they need to be more productive and have some opportunities that they don’t have today, I think that’s worth considering," Upmeyer told Radio Iowa.
Iowa Gov. Kim Reynolds didn't close the door to the idea, but she seems less enthusiastic about a requirement, instead focusing on the Future Ready Iowa program to bolster the state's workforce.
We think that's the right approach.
Advocates for a Medicaid work requirement say that work has worth, and it is counterproductive for people to stay off the job.
Of course, work has worth. But already 8 in 10 non-elderly adults covered by Medicaid who don't qualify because of a disability live in a working household, according to the Kaiser Family Foundation, a research organization. And a majority of them are working themselves.
Critics argue the real aim of a work requirement is to cut the program's costs. And, they note, the central purpose of Medicaid, which covers the poor and disabled, is to provide health insurance to people who wouldn't otherwise have it.
We worry a Medicaid work requirement in Iowa could have significant unintended consequences, especially if it’s rolled out with inadequate safeguards.
Consider what's happened in Arkansas, the first state to take advantage of the Trump administration’s move last year to open the door to a work requirement.
Arkansas requires that certain able-bodied people on its expanded Medicaid program be engaged in work or similar activities for 80 hours each month. If they don’t meet that requirement for three months, then they lose their health care coverage for the rest of the year, unless they are exempted.
Unfortunately, the phased implementation has been bumpy. At first, people were expected to fill out compliance forms through an online-only system. The state eventually had to add the option of reporting by phone because of problems.
In addition, there were a raft of reports about people being unaware of the new requirements at all, which has forced the state to expand its public education program.
Already, thousands of people in Arkansas have lost coverage. And, in November, a federal advisory panel urged the Trump administration to temporarily stop enforcement of the work requirement.
If all of this sounds a bit familiar, we understand. Iowa’s own conversion of its Medicaid program to managed care has had its own implementation problems. Services have been cut and doctors and hospitals have seen many of their claims go unpaid by the managed care organizations, sometimes for years.
The fact is, it took until late last year just to get a reliable estimate on the financial impact of converting to managed care.
So, we ask, why add a new requirement with the potential to cause even more dislocation?
Advocates for this kind of requirement say it is aimed at "able-bodied" adults, not at the disabled who rely on Medicaid for their health care but also to be able to function in society, live independently and, yes, to work.
But advocates for the disabled have expressed concerns nonetheless. One worry we've heard is how an "able-bodied adult" might be defined and whether people who are disabled might get caught up in this.
We understand the concern. A 2016 report from the Inspector General for the U.S. Department of Agriculture reported on the experience of state officials who were called on to administer a work requirement for "able-bodied adults without dependents" who were part of the Supplemental Nutrition Assistance Program (formerly known as food stamps).
Those officials called it an "operational nightmare" and "error-prone," according to the report. We worry about a repeat.
The Trump administration has already given permission to seven states to move forward with a work requirement. Some of these moves have been met with legal challenges.
We think Iowa's Medicaid program already has seen enough challenges in recent years, and it is complex enough as it is.
Instead of courting further headaches with big changes to the Medicaid program, we think lawmakers would do well to focus their efforts on programs they've already put in place for bolstering the state's workforce, like Future Ready Iowa.