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Medicaid Enrollees and Work Requirements: Lessons From the TANF Experience

Issue Brief
  1. While the future of federal legislation affecting Medicaid is unclear at this time, the American Health Care Act passed by the House of Representatives and the Better Care Reconciliation Act considered by the Senate both included a state option to require certain Medicaid adults to participate in approved work activities. Kaiser Family Foundation, Compare Proposals to Replace the Affordable Care Act,  https://www.kff.org/interactive/proposals-to-replace-the-affordable-care-act/.  Separately, some states are seeking Section 1115 waiver authority for Medicaid work requirements for adults newly eligible for coverage under the Affordable Care Act’s Medicaid expansion as well as for traditional Medicaid populations, such as low-income parents, those eligible for family planning services, and young adults aging out of foster care. Under the Obama Administration, CMS rejected state waiver requests for work requirements applied to Medicaid expansion adults as inconsistent with the program’s objectives to provide health coverage and care.  Kaiser Family Foundation, Section 1115 Medicaid Expansion Waivers:  A Look at Key Themes and State Specific Waiver Provisions (Aug. 2017), https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-expansion-waivers-a-look-at-key-themes-and-state-specific-waiver-provisions/; Kaiser Family Foundation, Proposed Medicaid Section 1115 Waivers in Maine and Wisconsin (July, 2017), https://www.kff.org/medicaid/issue-brief/proposed-medicaid-section-1115-waivers-in-maine-and-wisconsin/; Kaiser Family Foundation,  Medicaid and Work Requirements (March, 2017), https://www.kff.org/medicaid/issue-brief/medicaid-and-work-requirements/; Kaiser Family Foundation, Three Key Questions:  Section 1115 Medicaid Demonstration Waivers (Feb. 2017), https://www.kff.org/medicaid/issue-brief/3-key-questions-section-1115-medicaid-demonstration-waivers/ 

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  2. Section 1115 authorizes the Health and Human Services Secretary to authorize demonstration projects that test new approaches not otherwise permissible under federal law that, in Secretary’s judgment, advance program objectives.  Some states have created voluntary job training and referral programs for Medicaid adults, but CMS under the Obama Administration noted that these are state-funded programs separate from approved Medicaid expansion waivers.

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  3. Letter from HHS Secretary Thomas E. Price and CMS Administrator Seema Verma to State Governors (March 2017), https://www.hhs.gov/sites/default/files/sec-price-admin-verma-ltr.pdf.

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  4. 42 U.S.C. § 607.

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  5. Some of this research looked at the AFDC program, the predecessor to TANF.

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  6. Gayle Hamilton et al., National Evaluation of Welfare-to-Work Strategies: How Effective are Difference Welfare-to-Work Approaches? Five-Year Adult and Child Impacts for Eleven Programs, (Washington, DC: Manpower Demonstration Research Corporation, December 2001), http://www.mdrc.org/sites/default/files/full_391.pdf.

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  7. Id.

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  8. Kelley Bowden and Daisy Goodman, “Barriers to Employment for Drug Dependent Postpartum Women,” Work 50, 3(2015): 425-32; Dan Bloom, Pamela J. Loprest, and Sheila R. Zedlewski, TANF Recipients with Barriers to Employment (Washington, DC: Urban Institute, May 2012), http://www.urban.org/research/publication/tanf-recipients-barriers-employment; Benjamin G. Druss and Elizabeth Reisinger Walker, Mental disorders and medical comorbidity, (Princeton, NJ: The Robert Wood Johnson Foundation, February 2011), http://www.integration.samhsa.gov/workforce/mental_disorders_and_medical_comorbidity.pdf; Judith A. Cook, “Employment Barriers for Persons with Psychiatric Disabilities: Updated of a Report for the President’s Commission,” Psychiatric Services 57, 10(2006):1391-405; Ellen Meara, “Welfare Reform, Employment, and Drug and Alcohol Use Among Low-Income Women,” Harvard Review of Psychiatry 14, 4(2006): 223-32.

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  9. John Martinez et al., Results from the Substance Abuse Case Management Program in New York City (New York, NY: MDRC, May, 2009), https://www.mdrc.org/sites/default/files/full_551.pdf; The National Center on Addiction and Substance Abuse at Columbia University, CASASARDSM: Intensive Case Management for Substance-Dependent Women Receiving Temporary Assistance for Needy Families (New York, NY: The National Center on Addiction and Substance Abuse at Columbia University, January 2009), https://www.centeronaddiction.org/addiction-research/reports/casasard-intensive-case-management-substance-dependent-women-receiving; Dan Bloom et al., Alternative Welfare-to-Work Strategies for the Hard-to-Employ (New York, NY: MDRC, October 2009), http://www.mdrc.org/sites/default/files/full_19.pdf; Dan Bloom, Cynthia Miller, and Gilda Azurdia, Results from the Personal Roads to Individual Development and Employment (PRIDE) Program in New York City (New York, NY: MDRC, July 2007), http://www.mdrc.org/sites/default/files/full_547.pdf.

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  10. Dan Bloom, Cynthia Miller, and Gilda Azurdia, Results from the Personal Roads to Individual Development and Employment (PRIDE) Program in New York City (New York, NY: MDRC, July 2007), http://www.mdrc.org/sites/default/files/full_547.pdf.

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  11. Dan Bloom et al., Alternative Welfare-to-Work Strategies for the Hard-to-Employ (New York, NY: MDRC, October 2009), http://www.mdrc.org/sites/default/files/full_19.pdf.

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  12. Government Accountability Office, Temporary Assistance for Needy Families: Potential Options to Improve Performance and Oversight (Washington, DC: Government Accountability Office, May 2013), http://www.gao.gov/assets/660/654614.pdf.

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  13. Some people may have physical or mental health conditions that limit functioning in ways that create barriers to work, yet do not rise to the level of severity required to qualify for SSI benefits.

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  14. Mathematica Policy Research, Assisting TANF Recipients Living with Disabilities to Obtain and Maintain Employment:  Conducting In-Depth Assessments (Feb. 2008), https://www.acf.hhs.gov/sites/default/files/opre/conducting_in_depth.pdf.

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  15. Pamela Loprest, Disconnected Welfare Leavers Face Serious Risks (Washington, DC: Urban Institute, 2002), http://www.urban.org/sites/default/files/publication/59036/310839-Disconnected-Welfare-Leavers-Face-Serious-Risks.PDF.

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  16. Sharon Parrott, The New TANF Requirements and Individuals with Disabilities (Washington, DC: Center on Budget and Policy Priorities, March 2007), http://www.cbpp.org/research/the-new-tanf-requirements-and-individuals-with-disabilities.

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  17. Brenda J. Lohman et al., “Welfare Reform: What About the Children,” Welfare, Children & Families 02-1(2002): 1-8.

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  18. 42 U.S.C. § 601.

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  19. Drew Altman, Don’t Expect Medicaid Work Requirements to Make a Big Difference  Axios (April 2017), http://kff.org/medicaid/perspective/dont-expect-medicaid-work-requirements-to-make-a-big-difference/.

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  20. Excludes those receiving SSI benefits.  Kaiser Family Foundation, Understanding the Intersection of Medicaid and Work (Feb. 2017), https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/.

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  21. Ind. Family & Soc. Servs. Admin.  Amendment Request to Healthy Indiana Plan Section 1115 Waiver Extension Application (July 20, 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/in-healthy-indiana-plan-support-20-pa5.pdf.

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  22. Id. 

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  23. Maine Dep’t of Health & Human Servs. 1115 Waiver Application (Aug. 2, 2017), http://www.maine.gov/dhhs/oms/rules/MaineCare_1115_application_080217_to%20submit.pdf.

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  24. Kaiser Family Foundation, Understanding the Intersection of Medicaid and Work (Feb. 2017), https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/.

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  25. Kaiser Family Foundation, The Role of Medicaid in Rural America (April 2017), https://www.kff.org/medicaid/issue-brief/the-role-of-medicaid-in-rural-america/.

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  26. Kaiser Family Foundation analysis of 2015 American Community Survey 1-Year Estimates.

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  27. Kaiser Family Foundation, The Effects of Medicaid Expansion under the ACA:  Updated Findings from a Literature Review (Feb. 2017), https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review/.

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  28. Id.

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  29. Univ. of Mich. Institute for Healthcare Pol’y & Innovation, Medicaid Expansion Helped Enrollees Do Better at Work or in Job Searches (June 2017), http://ihpi.umich.edu/news/medicaid-expansion-helped-enrollees-do-better-work-or-job-searches.

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  30. Id. 

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  31. National Institute on Drug Abuse, Consequences of Drug Misuse (Bethesda, MD: National Institute on Drug Abuse, March 2017), https://www.drugabuse.gov/related-topics/health-consequences-drug-misuse; Neil Jordan et al., “Economic Benefit of Chemical Dependency Treatment to Employers,” Journal of Substance Abuse Treatment 34, 3(2008):311-319; Ronald C. Kessler et al., “Depression in the Workplace: Effects on Short-term Disability,” Health Affairs (Millwood) 18, 5(1999):163-71; Cheryl J. Cherpitel and Yu Ye, “Drug Use and Problem Drinking Associated with Primary Care and Emergency Room Utilization in the US General Population: Data from the 2005 National Alcohol Survey,” Drug and Alcohol Dependence 97 3(2008):226-30; Doris J. James and Lauren E. Glaze, Mental Health Problems of Prison and Jail Inmates (Washington, DC: US Department of Justice, December 2006), https://www.bjs.gov/content/pub/pdf/mhppji.pdf.

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  32. Kaiser Family Foundation, Medicaid’s Role in Addressing the Opioid Epidemic (June 2017); Kaiser Family Foundation, Medicaid’s Role in Behavioral Health (May 2017).

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  33. Kaiser Family Foundation, Understanding the Intersection of Medicaid and Work (Feb. 2017), https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/.

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  34. Id. 

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  35. See, e.g., Kaiser Family Foundation, Linking Medicaid and Supportive Housing:  Opportunities and On-the-Ground Examples (Jan. 2017), https://www.kff.org/report-section/linking-medicaid-and-supportive-housing-issue-brief/.

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  36. Calculated based on $2.9 billion total annual TANF spending on work activities and supports in 2015, https://www.cbpp.org/research/family-income-support/how-states-use-funds-under-the-tanf-block-grant, for 930,000 people required to participate in TANF work activities each month in 2015, https://www.acf.hhs.gov/ofa/resource/work-participation-rates-fiscal-year-2015 (Table 4B).  A work slot may be occupied by more than one person over the course of a year.

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  37. Kaiser Family Foundation, Section 1115 Medicaid Expansion Waivers:  A Look at Key Themes and State Specific Waiver Provisions (Aug. 2017), https://www.kff.org/medicaid/issue-brief/section-1115-medicaid-expansion-waivers-a-look-at-key-themes-and-state-specific-waiver-provisions/.

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  38. Proposed Amendment to Ark. Works Section 1115 Medicaid waiver (June 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-works-pa2.pdf.

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  39. Kentucky HEALTH Program Requirements Specification (April 4, 2017 draft), http://media.mcguirewoods.com/mwc/kentucky-medicaid-expansion-2.pdf (see especially pp. 34-44).

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  40. Id. at 35.

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  41. Kaiser Family Foundation, Proposed Changes to Medicaid Expansion in Kentucky (Aug. 2017), https://www.kff.org/medicaid/fact-sheet/proposed-changes-to-medicaid-expansion-in-kentucky/.

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  42. Ark. Proposed Amendment to Ark. Works Section 1115 Medicaid waiver (June 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-works-pa2.pdf.

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  43. Id. 

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  44. Sara Rosenbaum et al.  What Might a Medicaid Work Requirement Mean? (May 31, 2017), http://www.commonwealthfund.org/publications/blog/2017/may/medicaid-work-requirement.

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