Lauren was balancing two kids and law school as a single mom when an aching tooth threatened to derail her plans. There was one relief when the dentist told Lauren she would need surgery: KanCare, Kansas’ private Medicaid system, would cover the cost.
As full-time student, Lauren had a scholarship that prohibited her from working while she was in school. Since she was a single mom with no other access to insurance, Lauren depended on KanCare to cover health-care costs for her and her children, ages 7 and 9 at the time, during the three years she was in law school.
“Having dental coverage through KanCare was a huge relief,” Lauren said. “I would not have been able to afford insurance without it.”
While Medicaid largely covers children and disabled adults, Lauren represents a distinct population of people who access health care through Medicaid—parents or caregivers of dependent children. This population could lose insurance coverage should Kansas officials, in conjunction with the federal government, add work requirements to Medicaid eligibility.
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Kansas is one of 11 states that has submitted waiver proposals to the Centers for Medicare & Medicaid Services (CMS) to allow work requirements as a condition of eligibility for Medicaid. CMS has so far granted those waivers to Kentucky and Indiana—two states where legislators have expanded Medicaid under the Affordable Care Act (ACA), or Obamacare. Non-expansion states including Kansas, North Carolina, and Mississippi have also submitted waiver proposals.
In the waiver proposal Kansas submitted to CMS, the state says the work requirement— which would likely be either 20 or 30 hours a week, depending on if a single parent has a child younger than 6—could also be satisfied by volunteering or participating in job or vocational training, among other things.
North Carolina’s proposal is tied to a bill that would expand Medicaid, but without the expansion component in Kansas and Mississippi, parents will have great difficulty meeting both work requirements and income limits, said Suzanne Wikle, policy analyst with the Center for Law and Social Policy.
“In non-expansion states the families we are talking about who would be subject to the work requirement are really the poorest families,” Wikle said. “They are struggling to make ends meet on a daily basis.”
Kansas and Mississippi have some of the lowest income eligibility limits for Medicaid. As a caregiver in a family of three, for Lauren to qualify for KanCare, she can’t make more than $7,896 annually. A part-time minimum-wage job would likely put her over the income eligibility threshold, and while her kids would still have access to KanCare, she would not. Without Medicaid expansion, work requirements put parents with low incomes in a coverage gap—making too much money to qualify for Medicaid, but not enough to qualify for financial assistance on the insurance exchanges, said Sheldon Weisgrau, director of the Health Reform Resource Project, based in Topeka, Kansas.
“The basic disconnect in all of this is that work requirements are based off the idea that people still get insurance through their jobs. And that just isn’t true,” Weisgrau said. “There are so many jobs that put you in this coverage gap where you don’t make enough to qualify for financial assistance on the marketplace, and you are just out of luck.”
The work requirement in North Carolina is tied to a bill that includes Medicaid expansion, which puts progressives in a tough spot, said Ciara Zachary, health policy analyst with the North Carolina Justice Center. “We really have to think about the availability of jobs and who is going to oversee this,” Zachary said. “A lot of folks in the coverage gap are already part of families with a worker in it, and health care is the first step to being a healthy worker.”
Expansion remains elusive in Kansas and Mississippi. Kansas’ GOP-dominated legislature passed an expansion bill last year, but it was vetoed by then-Gov. Sam Brownback (R). Legislators failed to override Brownback’s veto. Brownback resigned in late January to serve as the U.S. ambassador-at-large for international religious freedom in the Trump administration.
While Kansas’ new governor, Republican Jeff Colyer has been quiet on the issue, he has voiced concerns over Medicaid expansion. GOP leaders in the Kansas state Senate issued a statement last month highlighting concerns with changes to KanCare, including work requirements, although the possibility of work requirements could still come up in expansion discussions, Weisgrau said.
Republican legislators in Mississippi rejected Medicaid expansion in 2013. Despite the Mississippi State Medical Association putting forth a resolution in 2016 calling for expanded access to Medicaid, GOP lawmakers have still not moved forward on the issue.
The push for work requirements as part of Medicaid mirrors the push for similar requirements as part of Temporary Assistance for Needy Families (TANF), which provides cash assistance to families with low incomes. Kansas officials adopted work requirements as part of TANF in 2011, and the number of families served by TANF since has been cut in half. In fact, Lauren could not qualify for TANF at the same time her family was using KanCare because she was not actively seeking work. She was a full-time graduate student.
“Kansas did this with TANF and the result has been that we have far fewer people receiving TANF than we used to, even though the number of poor people isn’t any different,” Weisgrau said.
Adding more hoops for people to jump through to access care further inhibits disadvantaged and economically vulnerable parents’ ability to keep themselves and their children healthy, Wikle said.
“We know that children are more likely to be insured if their parents are insured and we also know they are more likely to receive check-ups and regularly see the doctor when their parents are insured,” she said. “When you aren’t healthy, you can’t take care of your family. The evidence is pretty clear in showing that Medicaid acts as a support for work.”