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How Might Older Nonelderly Medicaid Adults with Disabilities Be Affected By Work Requirements in Section 1115 Waivers?

Most of the states with approved or pending Section 1115 waivers that condition Medicaid eligibility on work would apply those requirements to all or most nonelderly adults (ages 19-64) who are not receiving Supplemental Security Income (SSI) cash assistance, including older nonelderly adults (ages 50-64).1 Older nonelderly adults may be limited in their ability to satisfy a work requirement due to barriers resulting from age and/or disability. Previous analysis shows that many nonelderly Medicaid adults (ages 19-64) have functional limitations that may interfere with their ability to work but do not rise to the stringent SSI level of disability, making them potentially subject to work requirements. Older nonelderly adults are over twice as likely to have a disability than younger adults (17% vs. 7%).2 Furthermore, older nonelderly adults account for nearly half (45%) of all nonelderly Medicaid adults with a disability but not SSI who could be affected by a work requirement.3 This analysis examines the implications of work requirements for Medicaid adults ages 50 to 64 (referred to as “older nonelderly Medicaid adults”) and provides national and state level estimates of their disability, SSI, and work status using data from the 2016 American Community Survey (ACS).

How might older nonelderly #Medicaid adults ages 50 to 64 with disabilities be affected by #workrequirements in Section 1115 #waivers?

Key Findings

Of the 8.7 million older nonelderly Medicaid adults, nearly half (48%) report having a disability according to the ACS definition (Figure 1). The ACS classifies a person as having a disability if the person reports serious difficulty with hearing, vision, cognitive functioning (concentrating, remembering, or making decisions), mobility (walking or climbing stairs), self-care (dressing or bathing), or independent living (doing errands, such as visiting a doctor’s office or shopping, alone).4

Over half (53%) of older nonelderly Medicaid adults with a disability do not receive SSI cash assistance (Figure 1); these adults could be subject to a Medicaid work requirement, despite experiencing serious difficulty in at least one ACS functional area. Although the Centers for Medicare and Medicaid Services (CMS) work requirement guidance excludes people who are eligible for Medicaid based on a disability (such as those who receive SSI), many adults with disabilities will face Medicaid work requirements because they qualify for Medicaid on another basis (i.e., low-income).5 The CMS guidance allows states to apply work requirements to “working age” enrollees (those under age 65).  The guidance provides that states “may” provide exemptions from a work requirement, such as an exemption based on age, but leaves that decision up to the states. People subject to work requirements must verify that they are meeting the required number of hours or meet a specified exemption.

Figure 1: Disability and SSI Status of Nonelderly Adults Ages 50-64 with Medicaid, 2016

Eight of the 10 states with approved or pending Medicaid work requirement waivers as of March, 2018, would apply those requirements to all or most older nonelderly Medicaid adults.6 Just two states (Arkansas and Wisconsin) would exempt all older nonelderly (age 50+) Medicaid adults from work requirements. One state (Arizona) would exempt those age 55 and older, and two states (Indiana and Utah) would exempt those age 60 and older. Medicaid work requirements would apply to all older nonelderly Medicaid adults in the remaining five states (Kansas, Kentucky, Maine, Mississippi, and New Hampshire) under the current proposals (Table 1).

Table 1:  State Section 1115 Medicaid Work Requirement Waivers, as of March 13, 2018
State Waiver Status Covered Populations* Age Group Exemption
Arkansas Approved – implementation June, 2018 Expansion adults 50+
Arizona Pending Expansion adults 55+
Indiana Approved – implementation 2019 Expansion and traditional adults 60+
Kansas Pending Traditional adults (parents 0-38% FPL) 65+
Kentucky Approved – implementation July, 2018 Expansion and traditional adults 65+
Maine Pending Traditional adults (parents 0-105% FPL) 65+
Mississippi Pending Traditional adults (parents 0-27% FPL) 65+
New Hampshire Pending Expansion adults 65+
Utah Pending Traditional adults (parents 0-60% FPL; childless adults 0-100% FPL) 60+
Wisconsin Pending Traditional adults (childless adults 0-100% FPL) 50+
NOTE:  *Other groups, such as Transitional Medical Assistance, family planning only, or former foster care youth, may be included in some states. SOURCE:  Kaiser Family Foundation analysis of states’ Section 1115 waiver applications posted on Medicaid.gov.

In the eight states that would apply Medicaid work requirements to all or most older nonelderly adults, substantial shares of these adults have a disability but do not receive SSI, making them subject to the work requirement unless they are otherwise exempt.7 The share of older nonelderly Medicaid adults with a disability but not SSI in these states ranges from 39% in Utah8 to 64% in Arizona.9  These shares are 63% in Indiana10 and 53% in Kentucky, the two states with CMS approval to implement work requirement waivers that include all or most older nonelderly Medicaid adults to date (Figure 2).  (Arkansas also has CMS approval to implement a Medicaid work requirement, but, as indicated above, its waiver exempts adults ages 50 and over.)

Figure 2: SSI Status of Nonelderly Medicaid Adults Ages 50-64 with a Disability in States Proposing Medicaid Work Requirements, 2016

Just over 1 in 10 (13%) older nonelderly Medicaid adults with disabilities but not SSI are working 20 or more hours per week (Figure 3). The majority (83%) of older nonelderly Medicaid adults with a disability but not SSI are not working (unemployed or not in the labor force) (Table 3). For comparison, Kentucky’s approved waiver requires enrollees under age 65 to work 80 hours per month (equivalent to 20 hours per week), and Indiana’s approved waiver scales up to a requirement of 20 hours per week (after 18 months of enrollment) for those under age 60. Work rates vary, but are generally low, in the eight states with approved or pending Medicaid work requirement waivers that do not exempt any older nonelderly Medicaid adults based on age. In these states, the share of older nonelderly Medicaid adults with a disability but not SSI who are working 20 or more hours per week ranges from 10% in Mississippi to 16% in Kansas. (Figure 3).

Figure 3: Nonelderly Medicaid Adults Ages 50-64 with a Disability but Not SSI Working 20+ Hours Per Week in States Proposing Medicaid Work Requirements, 2016

Discussion

Most of the states with approved or pending Medicaid work requirement waivers would apply those requirements to all or most older nonelderly adults. Older nonelderly adults may face age-related barriers to complying with work requirements, and these barriers may be compounded for those who also have a disability. For example, people with low incomes are likely to be working in jobs with physical demands, such as being on one’s feet all day, walking, carrying or lifting heavy items, or performing repetitive motions. These jobs can be increasingly difficult to perform as people age. In addition, over half of older nonelderly Medicaid adults have a disability but do not receive SSI cash assistance. This population could be subject to work requirements despite experiencing a disability that limits their ability to work, such as a serious difficulty in the ability to hear; see; concentrate, remember, or make decisions; walk or climb stairs; or perform daily self-care and/or independent living tasks.

In Indiana and Kentucky, the two states with approved work requirement waivers that apply to all or most older nonelderly Medicaid adults, substantial shares of this population (63% in IN,11 and 53% in KY) have a disability but do not receive SSI. They therefore could be adversely affected if they do not comply with the work and documentation requirements or obtain an exemption, which depends on what the state exemption policies are and how they are implemented. By contrast, small shares of older nonelderly Medicaid adults with a disability but not SSI in these states are currently working at a level likely to satisfy the work requirement (20 or more hours per week, 13% in IN,12 and 15% in KY). Some older nonelderly adults with disabilities but not SSI might be exempt from the work requirement if they are determined to be “medically frail.” However, it is unclear whether everyone in this group will qualify for an exemption, how the process will work, and what specific criteria will apply.

Kentucky plans to implement its work requirement in July, 2018, and Indiana plans to implement in 2019. As these waivers are implemented, it will be important to monitor the impact on Medicaid beneficiaries, especially those whose older age and/or health status could affect their ability to comply. It will be important to assess how the work requirements and exemptions affect older nonelderly Medicaid adults with disabilities and the impact on access to coverage and care.

Table 2: Older Nonelderly Medicaid Adults by Disability and SSI Status, 2016
  Total Older Nonelderly Medicaid Adults Ages 50-64 Total Older Nonelderly Medicaid Adults with a Disability Older Nonelderly Medicaid Adults with a Disability but Not SSI
As a Share of Older Nonelderly Medicaid Adults with a Disability Number
US Total 8,730,300 4,161,500 53% 2,222,700
Alabama 117,300 75,100 43% 32,400
Alaska 14,600 6,700 54% 3,600
Arizona 214,200 97,600 64% 62,100
Arkansas 103,300 53,100 53% 28,300
California 1,455,700 506,400 57% 286,400
Colorado 134,200 59,000 61% 36,100
Connecticut 108,300 41,300 66% 27,100
Delaware 27,700 12,400 52% 6,400
DC 33,400 14,900 66% 9,800
Florida 465,700 251,400 48% 120,400
Georgia 192,900 121,000 39% 47,300
Hawaii 34,800 11,200 57% 6,500
Idaho 22,100 13,500 40% 5,500
Illinois 344,600 156,100 64% 99,600
Indiana 153,000 83,900 63% 53,100
Iowa 75,100 36,500 56% 20,400
Kansas 41,000 26,700 51% 13,600
Kentucky 192,900 104,400 53% 55,500
Louisiana 143,700 84,100 47% 39,200
Maine 41,600 25,500 46% 11,800
Maryland 148,000 71,900 56% 40,200
Massachusetts 275,700 105,800 56% 59,000
Michigan 344,200 180,400 54% 97,300
Minnesota 135,200 56,300 64% 36,300
Mississippi 83,900 53,300 49% 26,000
Missouri 110,400 70,200 59% 41,600
Montana 28,000 15,500 60% 9,300
Nebraska 20,700 13,000 49% 6,400
Nevada 76,700 34,700 59% 20,300
New Hampshire 25,900 11,500 57% 6,500
New Jersey 216,500 87,500 46% 40,000
New Mexico 85,400 40,500 56% 22,600
New York 811,100 290,400 53% 154,100
North Carolina 199,800 116,300 50% 57,800
North Dakota 10,300 5,700 51% 2,900
Ohio 331,200 162,100 64% 103,100
Oklahoma 61,000 41,300 50% 20,800
Oregon 140,100 63,400 58% 36,500
Pennsylvania 360,500 199,700 52% 104,800
Rhode Island 41,100 21,700 40% 8,700
South Carolina 109,700 67,700 47% 32,100
South Dakota 11,700 7,100 39% 2,800
Tennessee 178,100 114,300 47% 53,200
Texas 411,400 246,300 43% 106,300
Utah 32,200 18,900 39% 7,300
Vermont 26,800 9,800 52% 5,100
Virginia 99,400 57,700 58% 33,700
Washington 205,200 98,700 61% 60,000
West Virginia 84,900 45,900 54% 24,600
Wisconsin 140,000 68,200 54% 36,800
Wyoming 9,100 5,100 34% 1,700
NOTES: Includes non-institutionalized nonelderly adults ages 50-64. SSI = Supplemental Security Income. Disability includes serious difficulty with hearing, vision, cognitive functioning, mobility, self-care, or independent living. SOURCE: Kaiser Family Foundation analysis based on the 2016 American Community Survey, 1-Year Estimates.
 Table 3: Work Status of Older Nonelderly Medicaid Adults with a Disability but Not SSI, 2016
  Total Non-SSI Medicaid Adults with Disabilities, Ages 50-64 Total Working Share Working Share Working 20+ Hours/Week Share Working <20 Hours/Week Share Unemployed or Not in Labor Force
US Total 2,222,700 370,200 17% 13% 3% 83%
Alabama 32,400 2,500 8% 7% N/A 92%
Alaska 3,600 N/A N/A N/A N/A 85%
Arizona 62,100 10,600 17% 14% 3% 83%
Arkansas 28,300 3,200 11% 9% N/A 89%
California 286,400 53,300 19% 16% 3% 81%
Colorado 36,100 7,100 20% 14% 5% 80%
Connecticut 27,100 4,100 15% 12% N/A 85%
Delaware 6,400 1,600 24% 23% N/A 76%
DC 9,800 N/A N/A N/A N/A 84%
Florida 120,400 13,500 11% 9% N/A 89%
Georgia 47,300 4,600 10% 8% N/A 90%
Hawaii 6,500 N/A N/A N/A N/A 85%
Idaho 5,500 N/A N/A N/A N/A 84%
Illinois 99,600 16,200 16% 13% 3% 84%
Indiana 53,100 8,500 16% 12% N/A 84%
Iowa 20,400 5,500 27% 19% 8% 73%
Kansas 13,600 2,400 18% 16% N/A 82%
Kentucky 55,500 9,300 17% 15% N/A 83%
Louisiana 39,200 4,000 10% 8% N/A 90%
Maine 11,800 N/A N/A N/A N/A 87%
Maryland 40,200 9,000 22% 19% N/A 78%
Massachusetts 59,000 12,900 22% 16% 6% 78%
Michigan 97,300 18,300 19% 14% 5% 81%
Minnesota 36,300 11,000 30% 22% 9% 70%
Mississippi 26,000 3,000 11% 10% N/A 89%
Missouri 41,600 4,300 10% 8% N/A 90%
Montana 9,300 1,600 N/A N/A N/A 83%
Nebraska 6,400 N/A N/A N/A N/A 76%
Nevada 20,300 1,900 10% N/A N/A 90%
New Hampshire 6,500 N/A N/A N/A N/A 81%
New Jersey 40,000 7,400 18% 15% 4% 82%
New Mexico 22,600 5,800 26% 23% N/A 74%
New York 154,100 32,800 21% 18% 3% 79%
North Carolina 57,800 5,500 10% 8% N/A 90%
North Dakota 2,900 N/A N/A N/A N/A 92%
Ohio 103,100 17,500 17% 13% 3% 83%
Oklahoma 20,800 2,100 10% 10% N/A 90%
Oregon 36,500 7,800 21% 17% N/A 79%
Pennsylvania 104,800 19,000 18% 12% 6% 82%
Rhode Island 8,700 2,300 26% 25% N/A 74%
South Carolina 32,100 3,800 12% 10% N/A 88%
South Dakota 2,800 N/A N/A N/A N/A 84%
Tennessee 53,200 6,700 13% 11% 2% 87%
Texas 106,300 14,500 14% 11% 3% 86%
Utah 7,300 N/A N/A N/A N/A 87%
Vermont 5,100 N/A N/A N/A N/A 69%
Virginia 33,700 3,800 11% 10% N/A 89%
Washington 60,000 11,300 19% 13% 6% 81%
West Virginia 24,600 3,700 15% 12% N/A 85%
Wisconsin 36,800 6,200 17% 13% 4% 83%
Wyoming 1,700 N/A N/A N/A N/A 75%
NOTES: Includes non-institutionalized nonelderly adults ages 50-64. SSI = Supplemental Security Income. Disability includes serious difficulty with hearing, vision, cognitive functioning, mobility, self-care, or independent living. SOURCE: Kaiser Family Foundation analysis based on the 2016 American Community Survey, 1-Year Estimates.

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