After insisting that Medicaid enrollees will have to prove they are looking for full-time work in order to qualify for Medicaid coverage, Pennsylvania Gov. Tom Corbett is finally easing up on the requirement, which experts say was unlikely to be approved.
Pennsylvania is one of 26 states rejecting Medicaid expansion offered under the Affordable Care Act, despite the fact that the state has an increasing number of uninsured residents, bucking the national trend. The decision, blasted by health advocates, leaves 500,000 residents in the coverage gap—earning too much to quality for Medicaid but not enough to qualify for tax credits that would allow them to purchase plans under the state exchange.
In lieu of expansion, Gov. Corbett proposed a plan called Healthy PA. Call it an anti-expansion: It is the only state plan to slash benefits for current enrollees.
To reach residents stuck in the coverage gap, Healthy PA proposes to use federal subsidies to help uninsured low-income residents purchase privatized Medicaid insurance plans.
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From the initial proposal, Corbett and secretary of the Pennsylvania Department of Public Welfare Beverly D.Mackereth have insisted that enrollees will have to prove they are looking for full-time work to obtain benefits. The original draft of Healthy PA, published back in December, proposed that most enrollees between the ages of 21 and 65 working less than 20 hours a week demonstrate that they were fulfilling 12 job-searching activities a month in order to keep coverage.
No state has ever tethered Medicaid eligibility to searching for employment.
“Historically, work search and work promotion has not been among the statutory purposes of the Medicaid program,” MaryBeth Musumeci, associate director at the Kaiser Commission on Medicaid and the Uninsured, told Rewire. “Unlike the TANF [Targeted Assistance for Needy Families] program, Congress set out the purpose to be promoting work, whereas the purposes of Medicaid is promoting health care.”
After holding public hearings for feedback on the draft, the administration formally submitted the waiver to the federal government for approval in February. The submitted waiver was “gentler” and “softer” on some cuts and conditions proposed in the original draft, but Corbett remained steadfast about the job-search requirement; most enrollees working under 20 hours per week would have to prove they were seeking employment.
He called it the “Encouraging Employment” program.
Corbett’s notion is that the Encouraging Employment program would promote “personal responsibility,” a phrase that appears 30 times in the 202-page document.
From the waiver:
The goal of the Encouraging Employment program is to better enable low-income, able-bodied Pennsylvanians to move out of poverty while also gaining access to health care coverage.
The program will create an opportunity for unemployed and under-employed individuals to connect with potential employers.
The premise of the Encouraging Employment program ignores some basic facts about full-time employment and health insurance coverage. For one thing, the majority of people on Medicaid in Pennsylvania already work full-time, or live with someone who works full-time. Nationally, most uninsured workers are self-employed or work for small firms.
Secondly, the requirement assumes there are jobs to be found. Last week, FactCheck.org called Corbett out when he claimed that he has done a “remarkable” job creating new jobs in Pennsylvania in a series of statewide radio ads.
During his time in office, the number of government jobs has declined by a net 42,000 (most from local government jobs). When looking at all jobs, including government jobs, Pennsylvania has gained 96,300 total jobs under Corbett – a 1.7 percent job growth over three years, ranking the state 46th in total job growth among the states.
Despite the data, and the unlikelihood of the federal approval, the administration doubled down on the job-search requirement after submitting the waiver.
From Kaiser Health News and the Philadelphia Inquirer:
[T]he administration is sticking to its most controversial proposal: a requirement for work-search or job training.
“We believe it’s important,” said Mackereth. “Encouraging employment ties in strongly to good health outcomes.”
She said the goal is to remove people from public assistance. “We don’t want people to remain on government-funded health insurance. We’re providing tools for people to use.”
Last week, the administration signaled they are backing off. In a letter sent to Health and Human Services Secretary Kathleen Sebelius, Corbett proposed a “potential modification” to the waiver. From the letter, dated March 5:
This proposal will be a voluntary, one-year pilot program to positively encourage those who are able to work, to participate in job training and work opportunities … This pilot program will not be a condition of eligibility, but rather those individuals who participate will lower their premiums and cost sharing as incentives.
MaryBeth Musumeci told Rewire it’s not clear that making the requirement voluntary will be approved, either.
“It still remains to be seen. These waivers enter into a period of negotiation,” she said. “This is still subject to the federal-level comment period through the end of this month, and no decision by CMS would be made before then.”
Pennsylvanians can submit public comment here until March 28.
Donald Trump's running mate has said that "life is winning in Indiana"—and the biggest winner is probably a chain of crisis pregnancy centers that landed a $3.5 million contract in funds originally intended for poor Hoosiers.
Much has been made of Republican Gov. Mike Pence’s record on LGBTQ issues. In 2000, when he was running for U.S. representative, Pence wrote that “Congress should oppose any effort to recognize homosexual’s [sic] as a ‘discreet and insular minority’ [sic] entitled to the protection of anti-discrimination laws similar to those extended to women and ethnic minorities.” He also said that funds meant to help people living with HIV or AIDS should no longer be given to organizations that provide HIV prevention services because they “celebrate and encourage” homosexual activity. Instead, he proposed redirecting those funds to anti-LGBTQ “conversion therapy” programs, which have been widely discredited by the medical community as being ineffective and dangerous.
Under Pence, ideology has replaced evidence in many areas of public life. In fact, Republican presidential nominee Donald Trump has just hired a running mate who, in the past year, has reallocated millions of dollars in public funds intended to provide food and health care for needy families to anti-choice crisis pregnancy centers.
Gov. Pence, who declined multiple requests for an interview with Rewire, has been outspoken about his anti-choice agenda. Currently, Indiana law requires people seeking abortions to receive in-person “counseling” and written information from a physician or other health-care provider 18 hours before the abortion begins. And thanks, in part, to other restrictive laws making it more difficult for clinics to operate, there are currently six abortion providers in Indiana, and none in the northern part of the state. Only four of Indiana’s 92 counties have an abortion provider. All this means that many people in need of abortion care are forced to take significant time off work, arrange child care, and possibly pay for a place to stay overnight in order to obtain it.
This environment is why a contract quietly signed by Pence last fall with the crisis pregnancy center umbrella organization Real Alternatives is so potentially dangerous for Indiana residents seeking abortion: State-subsidized crisis pregnancy centers not only don’t provide abortion but seek to persuade people out of seeking abortion, thus limiting their options.
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“Indiana is committed to the health, safety, and wellbeing [sic] of Hoosier families, women, and children,” reads the first line of the contract between the Indiana State Department of Health and Real Alternatives. The contract, which began on October 1, 2015, allocates $3.5 million over the course of a year for Real Alternatives to use to fund crisis pregnancy centers throughout the state.
Where Funding Comes From
The money for the Real Alternatives contract comes from Indiana’s Temporary Assistance for Needy Families (TANF) block grant, a federally funded, state-run program meant to support the most vulnerable households with children. The program was created by the 1996 Personal Responsibility and Work Opportunity Reconciliation Act signed by former President Bill Clinton. It changed welfare from a federal program that gave money directly to needy families to one that gave money, and a lot of flexibility with how to use it, to the states.
This TANF block grant is supposed to provide low-income families a monthly cash stipend that can be used for rent, child care, and food. But states have wide discretion over these funds: In general, they must use the money to serve families with children, but they can also fund programs meant, for example, to promote marriage. They can also make changes to the requirements for fund eligibility.
As of 2012, to be eligible for cash assistance in Indiana, a household’s maximum monthly earnings could not exceed $377, the fourth-lowest level of qualification of all 50 states, according to a report by the Congressional Research Service. Indiana’s program also has some of the lowest maximum payouts to recipients in the country.
Part of this is due to a 2011 work requirement that stripped eligibility from many families. Under the new work requirement, a parent or caretaker receiving assistance needs to be “engaged in work once the State determines the parent or caretaker is ready to engage in work,” or after 24 months of receiving benefits. The maximum time allowed federally for a family to receive assistance is 60 months.
“There was a TANF policy change effective November 2011 that required an up-front job search to be completed at the point of application before we would proceed in authorizing TANF benefits,” Jim Gavin, a spokesman for the state’s Family and Social Services Administration (FSSA), told Rewire. “Most [applicants] did not complete the required job search and thus applications were denied.”
Unspent money from the block grant can be carried over to following years. Indiana receives an annual block grant of $206,799,109, but the state hasn’t been using all of it thanks to those low payouts and strict eligibility requirements. The budget for the Real Alternatives contract comes from these carry-over funds.
According to the U.S. Department of Health and Human Services, TANF is explicitly meant to clothe and feed children, or to create programs that help prevent “non-marital childbearing,” and Indiana’s contract with Real Alternatives does neither. The contract stipulates that Real Alternatives and its subcontractors must “actively promote childbirth instead of abortion.” The funds, the contract says, cannot be used for organizations that will refer clients to abortion providers or promote contraceptives as a way to avoid unplanned pregnancies and sexually transmitted infections.
Parties involved in the contract defended it to Rewire by saying they provide material goods to expecting and new parents, but Rewire obtained documents that showed a much different reality.
Real Alternatives is an anti-choice organization run by Kevin Bagatta, a Pennsylvania lawyer who has no known professional experience with medical or mental health services. It helps open, finance, and refer clients to crisis pregnancy centers. The program started in Pennsylvania, where it received a $30 million, five-year grant to support a network of 40 subcontracting crisis pregnancy centers. Auditor General Eugene DePasquale called for an audit of the organization between June 2012 and June 2015 after hearing reports of mismanaged funds, and found $485,000 in inappropriate billing. According to the audit, Real Alternatives would not permit DHS to review how the organization used those funds. However, the Pittsburgh Post-Gazettereported in April that at least some of the money appears to have been designated for programs outside the state.
Real Alternatives also received an $800,000 contract in Michigan, which inspired Gov. Pence to fund a $1 million yearlong pilot program in northern Indiana in the fall of 2014.
“The widespread success [of the pilot program] and large demand for these services led to the statewide expansion of the program,” reads the current $3.5 million contract. It is unclear what measures the state used to define “success.”
“Every Other Baby … Starts With Women’s Care Center”
Real Alternatives has 18 subcontracting centers in Indiana; 15 of them are owned by Women’s Care Center, a chain of crisis pregnancy centers. According to its website, Women’s Care Center serves 25,000 women annually in 23 centers throughout Florida, Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin.
Women’s Care Centers in Indiana received 18 percent of their operating budget from state’s Real Alternatives program during the pilot year, October 1, 2014 through September 30, 2015, which were mostly reimbursements for counseling and classes throughout pregnancy, rather than goods and services for new parents.
In fact, instead of the dispensation of diapers and food, “the primary purpose of the [Real Alternatives] program is to provide core services consisting of information, sharing education, and counseling that promotes childbirth and assists pregnant women in their decision regarding adoption or parenting,” the most recent contract reads.
The program’s reimbursement system prioritizes these anti-choice classes and counseling sessions: The more they bill for, the more likely they are to get more funding and thus open more clinics.
“This performance driven [sic] reimbursement system rewards vendor service providers who take their program reimbursement and reinvest in their services by opening more centers and hiring more counselors to serve more women in need,” reads the contract.
Classes, which are billed as chastity classes, parenting classes, pregnancy classes, and childbirth classes, are reimbursed at $21.80 per client. Meanwhile, as per the most recent contract, counseling sessions, which are separate from the classes, are reimbursed by the state at minimum rates of $1.09 per minute.
Jenny Hunsberger, vice president of Women’s Care Center, told Rewire that half of all pregnant women in Elkhart, LaPorte, Marshall, and St. Joseph Counties, and one in four pregnant women in Allen County, are clients of their centers. To receive any material goods, such as diapers, food, and clothing, she said, all clients must receive this counseling, at no cost to them. Such counseling is billed by the minute for reimbursement.
“When every other baby born [in those counties] starts with Women’s Care Center, that’s a lot of minutes,” Hunsberger told Rewire.
Rewire was unable to verify exactly what is said in those counseling sessions, except that they are meant to encourage clients to carry their pregnancies to term and to help them decide between adoption or child rearing, according to Hunsberger. As mandated by the contract, both counseling and classes must “provide abstinence education as the best and only method of avoiding unplanned pregnancies and sexually transmitted infections.”
In the first quarter of the new contract alone, Women’s Care Center billed Real Alternatives and, in turn, the state, $239,290.97; about $150,000 of that was for counseling, according to documents obtained by Rewire. In contrast, goods like food, diapers, and other essentials for new parents made up only about 18.5 percent of Women’s Care Center’s first-quarter reimbursements.
Despite the fact that the state is paying for counseling at Women’s Care Center, Rewire was unable to find any licensing for counselors affiliated with the centers. Hunsberger told Rewire that counseling assistants and counselors complete a minimum training of 200 hours overseen by a master’s level counselor, but the counselors and assistants do not all have social work or psychology degrees. Hunsberger wrote in an email to Rewire that “a typical Women’s Care Center is staffed with one or more highly skilled counselors, MSW or equivalent.”
Rewire followed up for more information regarding what “typical” or “equivalent” meant, but Hunsberger declined to answer. A search for licenses for the known counselors at Women’s Care Center’s Indiana locations turned up nothing. The Indiana State Department of Health told Rewire that it does not monitor or regulate the staff at Real Alternatives’ subcontractors, and both Women’s Care Center and Real Alternatives were uncooperative when asked for more information regarding their counseling staff and training.
Bethany Christian Services and Heartline Pregnancy Center, Real Alternatives’ other Indiana subcontractors, billed the program $380.41 and $404.39 respectively in the first quarter. They billed only for counseling sessions, and not goods or classes.
“We don’t provide medical services. We provide human services,” Bagatta told the City Paper.
There are pregnancy centers in Indiana that provide a full range of referrals for reproductive health care, including for STI testing and abortion. However, they are not eligible for reimbursement under the Real Alternatives contract because they do not maintain an anti-choice mission.
Parker Dockray is the executive director of Backline, an all-options pregnancy resource center. She told Rewire that Backline serves hundreds of Indiana residents each month, and is overwhelmed by demand for diapers and other goods, but it is ineligible for the funding because it will refer women to abortion providers if they choose not to carry a pregnancy to term.
“At a time when so many Hoosier families are struggling to make ends meet, it is irresponsible for the state to divert funds intended to support low-income women and children and give it to organizations that provide biased pregnancy counseling,” Dockray told Rewire. “We wish that Indiana would use this funding to truly support families by providing job training, child care, and other safety net services, rather than using it to promote an anti-abortion agenda.”
“Life Is Winning in Indiana”
Time and again, Bagatta and Hunsberger stressed to Rewire that their organizations do not employ deceitful tactics to get women in the door and to convince them not to have abortions. However, multiple studies have proven that crisis pregnancy centers often lie to women from the moment they search online for an abortion provider through the end of their appointments inside the center.
These studies have also shown that publicly funded crisis pregnancy centers dispense medically inaccurate information to clients. In addition to spreading lies like abortion causing infertility or breast cancer, they are known to give false hopes of miscarriages to people who are pregnant and don’t want to be. A 2015 report by NARAL Pro-Choice America found this practice to be ubiquitous in centers throughout the United States, and Rewire found that Women’s Care Center is no exception. The organization’s website says that as many as 40 percent of pregnancies end in natural miscarriage. While early pregnancy loss is common, it occurs in about 10 percent of known pregnancies, according to the American Congress of Obstetricians and Gynecologists.
Crisis pregnancy centers also tend to crop up next to abortion clinics with flashy, deceitful signs that lead many to mistakenly walk into the wrong building. Once inside, clients are encouraged not to have an abortion.
A Google search for “abortion” and “Indianapolis” turns up an ad for the Women’s Care Center as the first result. It reads: “Abortion – Indianapolis – Free Ultrasound before Abortion. Located on 86th and Georgetown. We’re Here to Help – Call Us Today: Abortion, Ultrasound, Locations, Pregnancy.”
Hunsberger denies any deceit on the part of Women’s Care Center.
“Clients who walk in the wrong door are informed that we are not the abortion clinic and that we do not provide abortions,” Hunsberger told Rewire. “Often a woman will choose to stay or return because we provide services that she feels will help her make the best decision for her, including free medical-grade pregnancy tests and ultrasounds which help determine viability and gestational age.”
Planned Parenthood of Indiana and Kentucky told Rewire that since Women’s Care Center opened on 86th and Georgetown in Indianapolis, many patients looking for its Georgetown Health Center have walked through the “wrong door.”
“We have had patients miss appointments because they went into their building and were kept there so long they missed their scheduled time,” Judi Morrison, vice president of marketing and education, told Rewire.
Sarah Bardol, director of Women’s Care Center’s Indianapolis clinic, told the Criterion Online Edition, a publication of the Archdiocese of Indianapolis, that the first day the center was open, a woman and her boyfriend did walk into the “wrong door” hoping to have an abortion.
“The staff of the new Women’s Care Center in Indianapolis, located just yards from the largest abortion provider in the state, hopes for many such ‘wrong-door’ incidents as they seek to help women choose life for their unborn babies,” reported the Criterion Online Edition.
If they submit to counseling, Hoosiers who walk into the “wrong door” and “choose life” can receive up to about $40 in goods over the course their pregnancy and the first year of that child’s life. Perhaps several years ago they may have been eligible for Temporary Assistance for Needy Families, but now with the work requirement, they may not qualify.
In a February 2016 interview with National Right to Life, one of the nation’s most prominent anti-choice groups, Gov. Pence said, “Life is winning in Indiana.” Though Pence was referring to the Real Alternatives contract, and the wave of anti-choice legislation sweeping through the state, it’s not clear what “life is winning” actually means. The state’s opioid epidemic claimed 1,172 lives in 2014, a statistically significant increase from the previous year, according to the Centers for Disease Control and Prevention. HIV infections have spread dramatically throughout the state, in part because of Pence’s unwillingness to support medically sound prevention practices. Indiana’s infant mortality rate is above the national average, and infant mortality among Black babies is even higher. And Pence has reduced access to prevention services such as those offered by Planned Parenthood through budget cuts and unnecessary regulations—while increasing spending on anti-choice crisis pregnancy centers.
Gov. Pence’s track record shows that these policies are no mistake. The medical and financial needs of his most vulnerable constituents have taken a backseat to religious ideology throughout his time in office. He has literally reallocated money for poor Hoosiers to fund anti-choice organizations. In his tenure as both a congressman and a governor, he’s proven that whether on a national or state level, he’s willing to put “pro-life” over quality-of-life for his constituents.
At the beginning of this month, around 1,500 children and 1,000 adults living in poverty in Arizona lost cash assistance and now are permanently barred from the state’s welfare program.
Arizona is the first state in the country to end welfare benefits after one year, meaning that a family—typically a parent or a relative with at least one dependent child—who has already used 12 months of cash assistance will be cut off permanently.
The approximately 2,500 individuals who lost benefits July 1 represent roughly 10 percent of the children and one-quarter of the adults who receive Arizona’s funds from a federal block-grant program known as Temporary Assistance to Needy Families (TANF). They may, however, still qualify for benefits like Supplemental Nutrition Assistance, Medicaid, and other assistance.
Arizona had previously provided two years of cash assistance, but Arizona lawmakers and the state’s Republican governor recently agreed to cut the time limit in half to help plug a projected $534 million budget hole in 2016 and shift themoney to state child welfare programs. The state expects to save $3.9 million annually with the 12-month limit, according to a spokesperson from the Arizona Department of Economic Security, which runs TANF.
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Critics have called it “an aggressive and intentional effort to undermine support for vulnerable families,” as Cynthia Zwick, executive director for the Arizona Community Action Association, put it for the Arizona Republic.
The average Arizona family in the program received $201 in May 2016, according to a state report, an amount that is less than half of the nationwide average monthly benefit of $429. To qualify in Arizona, a family of four generally cannot earn more than $2,584 a month, although that varies and is based on multiple factors.
A federal block-grant program, TANF was enacted under former President BillClinton in 1996 with the aim of “end[ing] welfare as we know it.” TANF allows up tofive years of benefits, but gives states wide latitude with those benefits, as long as their TANF spending meets at least one of four official goals: providing cash aid to needy families; promoting job training, work, and marriage; reducing out-of-wedlock pregnancies; and increasing the number of two-parent families.
In the 20 years since the program’s enactment, what’s happened is a marked and ongoing plunge in cash assistance to families in poverty, as states, like Arizona, spent TANF money elsewhere.
Roughly 55 percent of impoverished Arizona families received TANF benefits in 1994-95, a number that plunged to 9 percent in 2013, as the Morrison Institute noted in its 2015 report. Arizona’s latest reduction is the fourth since 2009, as the report noted.
Anticipating the cuts, representatives from the state DES said recently in a statement that state contractors have found jobs for more than 1,500 individuals who were in danger of losing benefits because of the new one-year cap.
Arizona outsources its job training and placement to two private companies, MAXIMUS and Arbor/ResCare Workforce Services. The DES also reported that an additional 245 individuals have gained work experience, and more than 450 have participated in community service activities with employers.