Blaming The Victim: West Virginia’s Flirtation With Medicaid Work Requirements

It was my intention when launching this blog to support economic policies in West Virginia that actually spread prosperity to all citizens. The wealthy don’t seem to need help ensuring they get a big plate full at the prosperity table. It is the less fortunate who need help. But in this long Republican winter, avoiding policies that hurt the less fortunate is really a full time job.

Two ideas popular in West Virginia and the nation today fuel this problem. First is the Koch-funded libertarian idea that any expansion of public benefits is a threat to the “liberty” of those who are taxed to pay for it. This is well-documented in Nancy MacLean’s 2017 book Democracy in Chains. Second is the populist notion that people who receive public benefits are somehow lazy and morally at fault for their situation. Both of these factors are on display in the current debate about whether to add work requirements for Medicaid benefits.

Medicaid is a jointly funded federal and state program that helps several categories of low income and disabled people with medical costs. As of 2017, Medicaid provided healthcare coverage to 74 million nationwide (over 23% of the population). Some of the covered categories include children in low-income families, pregnant women, parents of Medicaid-eligible children who meet certain income requirements, and low-income seniors.

Obamacare extended Medicaid eligibility to all U.S. citizens and legal residents with income up to 138% of the federal poverty line, including for the first time adults without dependent children. But as a result of a Supreme Court ruling, states were not required to adopt this expansion in order to receive federal Medicaid funding for previously covered groups. Given its large poor population, West Virginia wisely opted to extend coverage. About 170,000 additional West Virginians became eligible under Medicaid expansion, roughly 9% of the state’s population.

On January 11, 2018, the landscape changed. The Director of the federal Centers for Medicare and Medicaid Services (CMS) issued a letter to all state Medicaid directors inviting them to apply for a waiver that would allow states to require participation in work and other community engagement as a condition for Medicaid eligibility. The policy change is described as “designed to assist states in their efforts to improve Medicaid enrollee health and well-being through incentivizing work and community engagement.” Yes, you read that right. These bureaucrats are asserting that work will make you healthy. They cite studies that link unemployment with depression. Of course, they have it totally backwards – being healthy will enable you to work.

I am inclined to think that CMS’ explanation is a cynical effort to avoid the legal challenges to Medicaid work requirements that have already begun. In the first place, approving work requirement waivers is an about-face – several states attempted this in the past but were denied. They were denied because work requirements for eligibility are contrary to Medicaid’s stated purpose to provide comprehensive healthcare coverage for people below state income thresholds. Administrative agencies cannot lawfully rewrite a statute through adding eligibility requirements that advance other goals (limiting benefits to the “deserving poor”) that are contrary to the purpose of the law. CMS operatives know this, which explains their absurd effort to link work requirements with health.

At the urging of Republican legislators, West Virginia’s Department of Health and Human Resources is now considering work requirements for Medicaid recipients. According to Jeremiah Samples, Deputy Secretary of DHHR, this effort would focus on “able-bodied” people:

We’re trying to empower folks to get out of the system. At the end of the day, the best thing we can do at DHHR for our able-bodied population is to get them into the workforce, without question.

Truth be told, any such requirements would expel recipients from the system, not “empower” them to leave. This is a stick not a carrot. For Medicaid expansion states like West Virginia, any work requirements will have the (intended) effect of reducing the recipient population irrespective of whether those removed remain below the state income threshold.

How would this happen? According to Mr. Samples, the DHHR is reviewing how other states plan to add work requirements. Kentucky’s waiver was the first to be approved by CMS. The Kentucky plan calls for reporting by the recipient every 30 days to verify that he or she is working or involved in some other activity approved by the authorities. Kentucky will disenroll recipients from Medicaid for up to six months if they fail to report changes in income or work status.  Beyond the sheer hassle to the recipient and the possibility of inadvertent noncompliance, this would be yet another layer of red tape and opportunity for error. It would be a system the sole purpose for which is to snag and remove Medicaid recipients who do not repeatedly, month after month, prove their eligibility and worthiness. An aide to Kentucky Governor Blevins says that he expects 95,000 recipients to be removed from Medicaid benefits within five years.

Getting people off benefit rolls and onto employment rolls is a great idea. But West Virginia can’t do this by denying people healthcare. There are several reasons why an “able-bodied” person might be in need of Medicaid that have nothing to do with laziness. A shortage of jobs is one. Being between jobs for over 30 days is another. A mismatch between job requirements and a worker’s skill might be another. Opioid dependency might be involved. In an excellent editorial published on January 25, 2018, The Charleston Gazette put it this way:

How does interruption in coverage improve anything? Or is it just an exercise for the righteous . . . to feel better about themselves? ‘Must work for your healthcare,’ might be a great policy in the perfect imaginary world where ideologists live, but it fails to acknowledge the real circumstances of life in most of West Virginia, both town and country. No doubt that is by design. If people who never liked the Medicaid expansion can dress up their ‘solutions’ as getting tough on the poor and lazy, it sells better than if it is more accurately described as kicking the most vulnerable West Virginia workers, or potential workers.

Eighteen states declined to accept Medicaid expansion funds despite the needs of their populations. This group includes every state in the old Confederacy except Arkansas and Louisiana. But one unintended consequence of the present willingness of CMS to approve Medicaid work requirements is that several of these non-expansion states are now considering participation in the expansion. This may have the ultimate effect of increasing the Medicaid rolls nationwide. But it is a development that will not help expansion states like West Virginia.

West Virginia’s Other Public Health Crisis

Now that President Trump has declared that the opioid epidemic in this country is a national disaster, we may soon see more attention being paid to that health crisis in West Virginia. But there’s another health crisis in West Virginia that’s been festering under the radar: the epidemic of chronic disease and general poor health. According to the most recent report by the West Virginia Health Statistics Center, West Virginians have the second highest obesity rate in the country, the fifth highest rate of inactivity or lack of exercise, and the fifth highest rate of cancer. The state ranks first in the country for heart attacks, second for the prevalence of mental health problems and fourth for diabetes. Panhandle counties, particularly Jefferson, generally fare better than the rest of the state on these measures. Yet from any viewpoint, these statistics are troubling.

But unlike with opioids, recent science has shown there’s a quick, inexpensive, and certain cure for this crisis of poor health: it is our feet. When it comes to the epidemic of chronic illnesses that West Virginians are facing– cardiovascular, cancer, diabetes, orthopedic and even Alzheimer’s and depression– the remedy is to get moving.

Our current medical delivery system is a complicated mess, with most of the focus being on acute care fixes, and little on prevention. Primary care doctors can’t spend much time with individual patients. Insurers and the government reimburse for “procedures,” fixing what’s wrong after you’re sick, not preventing it in the first place. So the classic rule of economics applies. We get more of what we subsidize, and the US healthcare system rewards fixes—pills, coded treatment routines, but not prevention.

So the latest medical news is something that everyone in West Virginia and the rest of the nation should read and heed: simple, inexpensive and relatively easy forms of exercise can both extend lives and improve the quality of our years.

For 15 years, the nationally regarded Cooper Institute in Dallas compiled data from over 55,000 men and women on whether running – slog or speedy – showed health differences. In 2014, the published study showed a remarkable difference, regardless of how fast you moved, or how far. The overall risk of dying for movers went down 30 percent, and heart-related deaths declined 45 percent.

This year the news got even better. In a follow-up to the 2014 study, a new published study reexamined the Cooper data, added results from other recent related studies and reported even more striking benefits. If you regularly move some, regardless of pace or distance, you can add three years to your life. The study found as little as five minutes of daily running led to better life spans. Notably, the overall longevity benefits of 25 to 40 percent were found even after the scientists, in their syntax, controlled for such “confounding factors” as smoking, drinking, hypertension or obesity.

But wait, as the late-night infomercials say, there’s more. The health benefits weren’t just for better cardiovascular health, which showed a risk reduction of 45 to 70 percent when compared to non-runners. A similar powerful result was achieved from just walking. In addition, the report noted a 30 to 50 percent cancer death risk reduction, as well as an unquantified protection from death due to neurological conditions, such as Alzheimer’s and Parkinson’s. Just regular walking at a moderate pace lowered memory loss risk by up to 50%, slowed age-related declines in brain function, and improved cognitive task performance.

With all this compelling evidence, the question becomes what could government and employers do to help people get moving? To its credit, West Virginia has begun steps to formulate a plan to do just that. Two health-related initiatives at West Virginia University, along with a non-profit, have set up “ActiveWV 2015.” These groups took the generalized outline from the National Physical Activity Plan (NPAP) and began adapting it to fit the state’s unique challenges. Its most recent report says:

Examples of implementation activities include multiyear programs to provide resources and support to pre-K through 12th grade schools seeking to establish comprehensive school physical activity programs and a public awareness and social marketing campaign to promote physical activity using the people, programs, and places of West Virginia. Other examples include providing resources for primary care physicians interested in writing physical activity prescriptions based on use of local and state parks.

These are good ideas, and hopefully will produce long-term results. But are there other more concrete policy steps that might move things along faster? I think so. One is tempted to think how smoking was substantially reduced by treating it as a public health problem. Strong government efforts were implemented, such as warning notices on tobacco products, and graphic public ads on the adverse results of smoking. Then laws were passed prohibiting smoking in most public places, and slowly the tide turned against smoking. But could this approach be applied to increase physical activity? The problem is different. There is not one single behavior that needs to change. There is no single harmful product on which to affix warnings. More fundamentally, it probably is much easier to persuade people not to do something than to take positive action. Nevertheless, the public health campaign approach should not be ignored.

Here is my modest proposal for three concrete policy changes that would have significant public impact. First, motivate both primary care physicians and their patients to have a dialogue about the benefits of exercise, and to recognize when good exercise habits are being formed. The best way to do this is not some “command and control” regulation, but rather to find the right motivator. Most doctors already do a good job on the dialogue and tracking of blood pressure, cholesterol and insulin resistance. Perhaps some way to compensate doctors for positive changes in patient physical activity can be found, emphasizing prevention rather than cure. And while we are at it, why not find some creative way to reward patients financially for doing what they should do for themselves? Doing so would be far less expensive than the current healthcare approach.

Second, let’s build more public gyms and exercise facilities. Governments already find it a useful expenditure of public money to build and staff facilities for the preschool population as well as senior centers for the aging population. Today only a small proportion of people in the middle age groupings have sufficient resources to afford private health facility memberships. Indoor exercise facilities could be incorporated into, or become, community centers. The dollars spent on these type of facilities will substantially reduce the state’s soaring Medicaid expenditures and other public health costs.

Third, some employers acting in enlightened self-interest get their employees to engage in healthy activities and give them a small reward for doing so, often in the form of a modest reduction in their health insurance premium. Most of the time that reward is too small, so employers might create a scaled-up version of subsidies and rewards for exercise and related good health outcomes, sharing more of the employer’s healthcare expenses that are avoided.

West Virginia now has the medical and scientific evidence on how simple it can be to extend the quality and length of its citizens’ lives, and to reduce the soaring incidence and cost of chronic disease. This state could be an excellent laboratory for dramatic reductions in poor health indicators and set an example for the rest of the country. After all, there is nowhere to go but up.

 

Rep. Alex Mooney’s Feckless Vote on Healthcare

On May 4, 2017, the United States House of Representatives voted to pass the American Health Care Act (AHCA) by a narrow margin of 217 to 213, sending the bill to the Senate for deliberation. This Bill would repeal the majority of the Affordable Care Act (ACA) known as Obamacare, a promise made by Donald Trump and numerous Republican legislators during the 2016 campaign.

It is hard to describe in measured words the destructive impact the AHCA would have on West Virginia. Obamacare permitted the expansion of Medicaid benefits to large numbers of uninsured West Virginians. Because of this expansion we made great progress insuring low income, working adults, reducing the uninsured rate from 17% of the population to 5%. Repealing this feature of the law will cause 175,000 West Virginians to be uninsured once again.

One effect of the loss of health insurance is that people who need to see a doctor simply won’t. These people are at risk that their health status and earning capability will decline. Then there is opioid addiction, which has reached epidemic proportions in West Virginia. In 2016 approximately 20,000 people were treated for substance abuse disorder under the Medicaid expansion. This treatment will evaporate under AHCA. Some of the newly uninsured will get emergency treatment for illness and injury at hospitals and clinics. This is called uncompensated care.

When there is no insurance, who actually pays for uncompensated care? The people receiving care could pay out of their pockets. More likely, state and local governments or the hospitals and clinics themselves could be forced to absorb the cost. One projection estimates that West Virginia hospitals would be asked to provide $135 million more in uncompensated care annually.

Numerous national trade associations and interest groups operating in the healthcare space strongly opposed the AHCA. These included the AARP, The American Medical Association, The American Hospital Association, and Catholic Health Association of the United States. Even conservative groups such as Heritage Action and the Cato Institute opposed the AHCA.

In a series of three letters beginning in January 2017, two West Virginia Governors and the West Virginia Cabinet Secretary for Health and Human Services warned our Congressional delegation about the consequences of a repeal of Obamacare. On January 9, Governor Earl Ray Tomblin wrote to House majority leader Kevin McCarthy and the West Virginia delegation, noting that West Virginia’s population is one of the most rural and oldest in the nation, with poor health indicators. He said, “Federal funding must be maintained or West Virginia’s health care infrastructure will collapse.”

On February 15, Governor Jim Justice wrote a number of U.S Senators and sent copies to Rep. Mooney and the others in the West Virginia delegation. Justice said “Repeal of Medicaid expansion would eliminate up to $900 million from West Virginia’s healthcare economy annually” leading to the potential loss of 16,000 jobs.

None of these entreaties had the desired effect on Rep. Mooney — he voted in support of the AHCA. His official statement began as follows: “Today, I was proud to vote for the American Health Care Act. I pledged to voters in the Second District that I would vote to repeal and replace Obamacare and today I fulfilled that pledge.” His statement pointed to the “collapsing market” for health insurance and asserted that the free market would provide better options for people who can afford insurance, but offered not one word concerning the large swath of West Virginians who will be rendered uninsured or the impact of repeal on West Virginia’s economy.

Why would our Congressman vote for the AHCA in the face of unrebutted information that it would devastate the lives of many West Virginians and deal another blow to our economy? One answer is to take him at his word – he promised to do it and he was determined to keep his promise. While there is something to be said for keeping promises, the moral value of doing so here is petty in comparison to the moral imperative to protect hundreds of thousands of people who would lose healthcare coverage.

There is a less attractive explanation that may be closer to the truth. A vote in favor of the AHCA was demanded by President Trump and the House Republican hierarchy, and Rep. Mooney did not have the fibre to oppose them despite the cost to his constituents. More likely he was happy to join with them for ideological reasons despite the costs to his constituents.

As for being “proud” of his position on the AHCA, Rep. Mooney certainly has not acted like it. In March when he and Senator Joe Manchin met with constituents at a state Congressional reception in Washington, D.C., many of the attendees aggressively questioned Rep. Mooney about the AHCA. Mooney fled the room when he could no longer provide answers. Subsequently, he was quoted in the Martinsburg Journal claiming that these people were “professionally trained radicalists.” But in the comments submitted by readers of the Journal’s original March 11, 2017 article about the incident, Sara Le Rana said:

I was in attendance as an interested citizen. I WAS NOT paid or a “professionally trained radicalist.” I’m uncertain what that is. Mooney RAN, not walked, he RAN rather than stay and do his job. Manchin listened, encouraged the guests closer to him. Mooney refused to listen or stay to respond in a respectful manner . . . . The dude ran.

This evasive behavior on the part of Rep. Mooney has been typical of his lack of responsiveness, and that of his staff, in large part around the healthcare issue. West Virginians deserve better than this.

2018 cannot come soon enough.

Trump Voters Now Have Second Thoughts on Repealing Obamacare

The Kaiser Family Foundation has issued the results of a new poll concerning repeal of Obamacare. Anyone with a pulse knows that repeal has been made a rallying cry for Republicans in Congress, in fact their centerpiece in the ideological attack on the Obama administration. But it appears that Republican ideology has gotten out ahead of the desires of voters, who are not as much interested in ideology as they are in understandable, affordable and stable healthcare.

When asked about a series of health care priorities for President-elect Trump and the next Congress to act on, repealing the ACA falls behind other health care priorities. Two-thirds of the public (67 percent) say lowering the amount individuals pay for health care should be a “top priority” for President-elect Trump and the next Congress. This is followed by six in ten (61 percent) who say lowering the cost of prescription drugs should be a “top priority,” and nearly half (45 percent) who say dealing with the prescription pain killer addiction epidemic should be a “top priority.”

When given two competing approaches to the future of health care, six in ten Americans (62 percent) prefer “guaranteeing a certain level of health coverage and financial help for seniors and lower-income Americans, even if it means more federal health spending and a larger role for the federal government” while about one-third (31 percent) prefer “limiting federal health spending, decreasing the federal government’s role, and giving state governments and individuals more control over health insurance, even if this means some seniors and lower-income Americans would get less financial help than they do today.” This level of support  for federal healthcare spending is the stake in the heart of the conservative ideological vampire.

Overall, 49 percent of the public think the next Congress should vote to repeal the law and 47 percent say they should not vote to repeal it. But of those who want to see Congress vote to repeal the law, a larger share say they want lawmakers to wait to vote on repeal until the details of a replacement plan have been announced (28 percent) than say Congress should vote to repeal the law immediately and work out the details of a replacement plan later (20 percent).

In its reporting on the KFF poll, the Washington Post pointed out that the same repeal question has been asked 16 times in the last two years and the most recent poll results show the lowest support for immediate repeal without a replacement — a drop of 6% since October. The biggest part of this drop is among Republicans whose support for immediate repeal without replacement has dropped 17%.

In 2016 Rep. Alex Mooney, the Panhandle’s Congressional representative, voted to repeal Obamacare through budget reconciliation. That is once again the method favored by Congressional Republicans. Attention Rep. Mooney! Only 20% of all respondents in the KFF poll want you to repeal Obamacare without a replacement. Here’s hoping you can think for yourself.

Sen. Joe Manchin can spot a bad deal for West Virginia when he sees one. Manchin told reporters on January 4, 2017 that he would not vote to repeal the ACA without a replacement on the table. Manchin’s office said that if the law is repealed, 172,000 West Virginians would lose health insurance coverage and the state would lose $840 million in federal funds to provide health care for low-income families.

“Most of the people [in West Virginia] that have benefited from this one way or another voted for Trump,” Manchin said. “They don’t know what they have or how they got it. I will tell you this: You repeal it and take it away, they will know who took it away.”

Progressives may be conflicted. Sen. Charles Schumer urges Democrats not help the Republicans in Congress come up with a prompt replacement if they vote to repeal immediately through budget reconciliation. His view is let the Republicans suffer the wrath of the voters for creating the unnecessary healthcare disaster that Sen. Manchin predicts. That is certainly attractive in a partisan way, but it seems like more one-upmanship and political posturing. The real suffering from this approach will be by the people who are back to having no healthcare.

Repeal of Obamacare: A Disaster for West Virginia

In January 2016, Congress passed a budget reconciliation bill repealing much of the Affordable Care Act by simply removing the funding for it. President Obama vetoed the bill. Now congressional Republicans threaten to do the same in the upcoming new session.

Most likely, Congress will not have a replacement for the ACA ready to go for quite some time. Republican leaders propose to make some provisions of the repeal effective immediately and defer the effectiveness of other provisions until a replacement bill can be passed.

A repeal through a reconciliation bill can only affect those provisions that have an impact on the federal budget. Among those is the expansion of Medicaid adopted by 31 states, including West Virginia. A recent study by the Urban Institute details the disastrous effects on the nation’s healthcare system of a repeal by reconciliation, even if the effectiveness of major parts of the repeal is delayed two years.

The bottom line is that repeal by reconciliation will hit states like West Virginia the hardest because these states would lose the most federal funding. Even if the elimination of funding for Medicaid expansion were to be delayed until 2019, the number of uninsured in West Virginia would rise from 88,000 now to 272,000 in 2019 – an increase of 208%.

Who will become uninsured? The Urban Institute study predicts that nationwide 82% of the newly uninsured would be members of working families and 56% would be non-Hispanic whites. A majority of the newly uninsured – 53% –would have earnings between 100% and 400% of the federal poverty level. Another 25% would be people with incomes below the poverty level.

One effect of the loss of health insurance is that people who need to see a doctor simply won’t. These people are at risk that their health status and earning capability will decline. And uninsured health emergencies are often the cause of a breakdown in family financial stability. Others will get emergency treatment at hospitals and clinics, but will have no insurance to pay for it. This is called uncompensated care.

How does uncompensated care get paid for? The people receiving care may pay out of their pockets. More likely, state and local governments or the hospitals and clinics themselves could be forced to absorb the cost. On December 6, 2016, the two main hospital trade groups sent a letter to President-elect Trump and congressional leaders stating that repealing Obamacare could cost hospitals $165 billion by the middle of the next decade and trigger “an unprecedented public health crisis.”

A recent  op-ed piece in the Charleston Gazette by Renate Pore, Chairwoman of the West Virginia Medicaid Coalition, said correctly that “[h]undreds of thousands of lives — pregnant women, children, working parents, seniors, people in nursing homes and who need long-term care – every family in West Virginia has a real stake in this debate.”

West Virginia voted for President-elect Trump, and our congressional representation is heavily Republican. Now is the time for them to help West Virginia avoid the financial disaster that would occur through a repeal of Obamacare that does not simultaneously replace it with acceptable policies and federal spending to insure the poor and middle class.