Tag: Medicaid work requirements

Trump challenges Native Americans’ historical standing

The Trump administration says Native Americans might need to get a job if they want to keep their health care — a policy that tribal leaders say will threaten access to care and reverse centuries-old protections.

Tribal leaders want an exemption from new Medicaid work rules being introduced in several states, and they say there are precedents for health care exceptions. Native Americans don’t have to pay penalties for not having health coverage under Obamacare’s individual mandate, for instance.

But the Trump administration contends the tribes are a race rather than separate governments, and exempting them from Medicaid work rules — which have been approved in three states and are being sought by at least 10 others — would be illegal preferential treatment. “HHS believes that such an exemption would raise constitutional and federal civil rights law concerns,” according to a review by administration lawyers.

The Health and Human Services Department confirmed it rebuffed the tribes’ request on the Medicaid rules several times. Seema Verma, administrator of the Centers for Medicare & Medicaid Services, conveyed the decision in January, and officials communicated it most recently at a meeting with the tribes this month. HHS’ ruling was driven by political appointees in the general counsel and civil rights offices, say three individuals with knowledge of the decision.

Senior HHS officials “have made it clear that HHS is open to considering other suggestions that tribes may have with respect to Medicaid community engagement demonstration projects,” spokeswoman Caitlin Oakley said, using the administration’s term for work requirements that can also be fulfilled with job training, education and similar activities.

The tribes insist that any claim of “racial preference” is moot because they’re constitutionally protected as separate governments, dating back to treaties hammered out by President George Washington and reaffirmed in recent decades under Republican and Democratic presidents alike, including the Clinton, George W. Bush and Obama administrations.

“The United States has a legal responsibility to provide health care to Native Americans,” said Mary Smith, who was acting head of the Indian Health Service during the Obama administration and is a member of the Cherokee Nation. “It’s the largest prepaid health system in the world — they’ve paid through land and massacres — and now you’re going to take away health care and add a work requirement?”

Tribal leaders and public health advocates also worry that Medicaid work rules are just the start; President Donald Trump is eyeing similar changes across the nation’s welfare programs, which many of the nearly 3 million Native Americans rely on.

“It’s very troublesome,” said Caitrin McCarron Shuy of the National Indian Health Board, noting that Native Americans suffer from the nation’s highest drug overdose death rates, among other health concerns. “There’s high unemployment in Indian country, and it’s going to create a barrier to accessing necessary Medicaid services.”

Native Americans’ unemployment rate of 12 percent in 2016 was nearly three times the U.S. average, partly because jobs are scarce on reservations. Low federal spending on the Indian Health Service has also left tribes dependent on Medicaid to fill coverage gaps.

“Without supplemental Medicaid resources, the Indian health system will not survive,” W. Ron Allen — a tribal leader who chairs CMS’ Tribal Technical Advisory Group — warned Verma in a Feb. 14 letter.

The Trump administration has allowed three states — Arkansas, Kentucky and Indiana — to begin instituting Medicaid work requirements, and at least 10 other states have submitted or are preparing applications. More than 620,000 Native Americans live in those 13 states, according to 2014 Census data. And more states could move in that direction, heightening the impact.

Some states, like Arizona, are asking HHS for permission to exempt Native Americans from their proposed work requirements. But officials at the National Indian Health Board say that may be moot, as federal officials can reject state requests.

Tribal officials say their planning process has been complicated by HHS’ refusal to produce the actual documents detailing why Native Americans can’t be exempted from Medicaid work requirements. “The agency’s official response was that they couldn’t provide that [documentation] because of ongoing, unspecified litigation,” said Devin Delrow of the National Indian Health Board. HHS did not respond to a question about why those documents have not been made available.

While the tribes say they hope to avoid a legal fight, their go-to law firm — Hobbs, Straus, Dean & Walker LLP — in February submitted a 33-page memo to the Trump administration, sternly warning officials that the health agency was violating its responsibilities.

“CMS has a duty to ensure that [Native Americans] are not subjected to state-imposed work requirements that would present a barrier to their participation in the Medicaid program,” the memo concludes. “CMS not only has ample legal authority to make such accommodations, it has a duty to require them.”

Meanwhile, tribal leaders say the Trump administration has signaled it may be seeking to renegotiate other aspects of the government’s relationship with Native Americans’ health care, pointing to a series of interactions they say break from tradition.

“This doesn’t seem to be isolated to the work requirements,” said McCarron Shuy of the National Indian Health Board.

The Trump administration also targeted the Indian Health Service for significant cuts in last year’s budget, though Congress ignored those cuts in its omnibus funding package last month, H.R. 1625 (115). The White House budget this year proposed eliminating popular initiatives like the decades-old community health representative program — even though tribal health officials say it is essential.

Tribal officials noted that both HHS Secretary Alex Azar and Deputy Secretary Eric Hargan skipped HHS’ annual budget consultation with tribal leaders in Washington, D.C., last month. The secretary’s attendance is customary; then-HHS Secretary Tom Price joined last year. However, Azar canceled at the last minute. His scheduled replacement, Hargan, fell ill, so Associate Deputy Secretary Laura Caliguri participated in his place. That aggravated tribal leaders who were already concerned about the Trump administration’s policies.

Another point of contention for the tribes is that HHS’ civil rights office — while rejecting Native Americans’ Medicaid request on grounds that they’re seeking an illegal preference — simultaneously announced new protections sought by conservative religious groups.

HHS further stressed that the administration remains committed to Native Americans’ health.

“Secretary Azar, HHS, and the Trump administration have taken aggressive action and will continue to do so to improve the health and well-being for all American Indians and Alaska Natives,” according Oakley, of HHS.

But tribal leaders and public health experts say the administration’s record hasn’t matched its rhetoric. “Work requirements will be devastating,” said Smith, the former Indian Health Service acting director. “I don’t know how you would implement it. There are not jobs to be had on the reservation.”

[Politico]

Trump order targets wide swath of public assistance programs

The Trump administration is seeking to completely revamp the country’s social safety net, targeting recipients of Medicaid, food stamps and housing assistance.

Trump is doing so through a sweeping executive order that was quietly issued earlier this week – and that largely flew under the radar.

It calls on the Departments of Health and Human Services, Housing and Urban Development, Agriculture and other agencies across the federal government to craft new rules requiring that beneficiaries of a host of programs work or lose their benefits.

Trump argued with the order, which has been in the works since last year, that the programs have grown too large while failing to move needy people out of government help.

“Since its inception, the welfare system has grown into a large bureaucracy that might be susceptible to measuring success by how many people are enrolled in a program rather than by how many have moved from poverty into financial independence,” it states.

The order is directed at “any program that provides means-tested assistance or other assistance that provides benefits to people, households or families that have low incomes.”

Democrats have blasted the effort, arguing the order blends the issues of welfare and broader public assistance programs in a deliberate way they say is intended to lower support for popular initiatives.

“Welfare” has historically been used to describe cash assistance programs like Temporary Assistance for Needy Families. Democrats and liberal activists say the Trump administration is seeking to expand the definition of welfare to mean food stamps, Medicaid and other programs as a way to demonize them.

“This executive order perpetuates false and racist stereotypes about certain groups supposedly taking advantage of government assistance,” House Democratic Whip Steny Hoyer (Md.) and Rep. Barbara Lee (D-Calif.) said in a joint statement reacting to the order.

President Trump “is trying to erect a smokescreen in the shape of Reagan’s ‘welfare queen’ so people don’t see he’s coming after the entire middle and working class,” said Rebecca Vallas, managing director of the Center for American Progress’s Poverty to Prosperity Program.

Welfare reform has long been a goal of GOP lawmakers, and there’s broad support in the Republican conference for changing the federal safety net to impose stricter work requirements and block grant state funding for programs like Medicaid and food stamps.

While noting that he hadn’t seen the specific text of the executive order, Rep. Tom Cole (R-Okla.) said he supports the concept.

“For able-bodied, single adults, I certainly favor work requirements,” Cole said.

With Republicans in total control of the government, conservatives have been hoping for a major legislative push to overhaul federal assistance programs.

Speaker Paul Ryan (R-Wis.) late last year said he wanted Republicans to work on entitlement reform, with a focus on promoting work and career-based education.

“We want to smooth the path from welfare to work, pull people out of poverty, pull people out of welfare,” Ryan said in December.

Robert Rector, a senior research fellow at the Heritage Institute, said the executive order is meant to signal support to congressional Republicans.

“[Administration officials] have been talking to Congress, and the executive order is designed to set the table for them,” Rector said. “Do what they can in the executive branch, and give support to similar efforts on the Hill.”

But a short legislative calendar and a slim Republican majority in the Senate mean the administration may be largely on its own.

Agencies are limited in what changes they can make to their programs, so comprehensive welfare reform may be off the table without major legislation.

Republicans have already acknowledged they won’t be able to cut spending on entitlement programs like Medicare, Medicaid and Social Security.

“I think it’s very tough to get this thing through the Senate when it requires 60 votes. I certainly don’t have any problem with the president taking initiative,” Cole said.

The executive order doesn’t set any new policy, but Center for American Progress’s Vallas said the order is important as a messaging document, and it shows that Trump is willing to act without Congress.

“This is more of President Trump not being content to wait for Congress to dismantle these programs. This is him wanting to take matters into his own hands,” Vallas said.

The order follows policy shifts already underway at various agencies.

Health and Human Services officials have encouraged states to pursue work requirements for Medicaid beneficiaries. Arkansas, Indiana and Kentucky have already been granted such waivers, and several other states have waivers pending with the administration.

Earlier this year, the Agriculture Department sought input on “innovative ideas to promote work and self-sufficiency among able-bodied adults” participating in the food stamp program.

In Congress, House Republicans unveiled a provision in the 2018 farm bill to expand mandatory work requirements in the food stamp program. The broader legislation will be marked up later this month, but it faces a long uphill battle.

The administration’s effort could also face legal challenges. Medicaid advocates in Kentucky have already sued over the work requirements, and additional safety net changes could provoke even more lawsuits.

[The Hill]

Trump approves Arkansas Medicaid work requirements

Arkansas on Monday became the third state to get the Trump administration’s permission to impose work requirements on Medicaid beneficiaries.

The Centers for Medicare and Medicaid Services approved a Medicaid waiver that included a requirement for recipients to work, or participate in job training or job search activities for 80 hours a month.

State officials said they will begin implementing the work requirements June 1, making them the first state to do so. If a person fails to meet the requirements for three months, he or she will lose coverage for the rest of that calendar year.

However, the state did not get approval to roll back the eligibility level for Medicaid beneficiaries. If that provision had been approved, an estimated 60,000 people would have lost coverage.

Arkansas expanded Medicaid under ObamaCare to people earning up to 138 percent of the federal poverty level, and receives federal funding to pay for those new enrollees. But Gov. Asa Hutchinson (R) sought to restrict the program so that only people who are at the federal poverty level would be eligible.

The so-called “partial expansion” was a key test of the limits of the Trump administration’s power on how far states could go to limit Medicaid enrollment. Arkansas officials sought to reduce eligibility, while still getting the same level of federal funding.

[The Hill]

Reality

Work requirements don’t make more people work, because most recipients already work, they just throw them off benefits.