Kentucky wants to require its Medicaid recipients to work a certain number of hours—and report that they are working the hours—to keep receiving the essential health care coverage. 

Despite estimates that the new requirements would mean that well over 100,000 people would experience short-term gaps in coverage, the Department of Health and Human Services (HHS) signed-off on what is being called the Kentucky HEALTH program. And HHS granted approval even though the court invalidated HHS’ approval of an earlier version of Kentucky HEALTH, opining that the federal agency didn’t consider whether the program “would help provide health coverage for Medicaid beneficiaries.” 

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A group of Medicaid enrollees challenged the re-approved Kentucky HEALTH that is nearly identical to the first one in a lawsuit filed in the U.S. District Court for the District of Columbia. 

Noting the “severe harms that it will inflict on Kentucky Medicaid beneficiaries,” the Litigation Center of the American Medical Association and State Medical Societies joined with the American Academy of Pediatrics, the American College of Physicians, the American Psychiatric Association and others in a friend-of-the-court brief in Stewart v. Azar that urges justices to stop the planned changes.

“The work requirements, the premiums, the lockout period, the elimination of non-emergency medical transportation benefits and the elimination of retroactive eligibility will simply increase the numbers of the short- and long-term uninsured,” the brief tells the court. “HHS and Kentucky never accounted for how this loss of coverage will produce dramatically worse health outcomes.” 

The AMA works to improve Medicaid programs, expand coverage options and make it easier for physicians to see Medicaid patients. The AMA has policy stating that, if invited to do so by the state medical society, it will work with state and specialty medical societies to expand Medicaid eligibility. 

Misguided work requirement  

Kentucky officials say they want to enact the law because the changes will lift beneficiaries out of unemployment, improve health outcomes and strengthen the social safety net. 

Physicians disagree. 

Estimates show nearly 165,000 Kentucky Medicaid enrollees are not working and would not be exempt from Kentucky HEALTH’s new work requirements. Many of these enrollees have health conditions limiting their work, others are in economically depressed areas or lack the skill and education to find a job. 

Another 55,000 enrollees work too inconsistently to be covered the entire year, as the requirements expect a person to work at least 20 hours a week for 48 weeks of the year for a total of 960 hours annually.  

“Thinly veiled threats or ‘incentives’ will not help beneficiaries enter the workforce or obtain steadier employment. Holding health coverage hostage will only exacerbate these problems,” the AMA Litigation Center brief states. Without health insurance, it notes, many will have a harder time holding down a job; others will have a harder time finding a job.

And people would lose access to care for other reasons under the new program. Kentucky HEALTH would cut off non-emergency transportation that many rely on to get to doctor appointments, set monthly premiums that the commonwealth’s poorest won’t be able to pay, and lock people out of the program for a period of time if they miss a single payment or don’t properly verify or document their employment. 

Worse health outcomes loom 

Patients unenrolled from Medicaid will lose preventive care services that are particularly important for Medicaid-eligible adults who have higher rates of chronic conditions. Patients being treated for a mental illness, cancer or other ailments, and patients taking prescription drugs for conditions such as hypertension stand to suffer worse health outcomes, the amici tell the court. 

These declines would come after Kentucky made great strides in improving health care coverage. After the commonwealth expanded eligibility to more than 454,000 newly eligible beneficiaries in 2014, the uninsured rate for the low-income population plummeted to 8.6 percent in 2016. The rate was 40.2 percent in 2013. 

“Newly covered adults experienced a 41-percentage point increase in having a usual source of care,’” the brief says. “Kentucky HEALTH reverses course. Some may die prematurely as a result. Indeed, one life is saved for approximately every 250-300 people who gain coverage.” 

On top of all of that, the program will cost Kentucky more money in the long run and safety-net providers—hospitals, community health centers, local health departments and others—may be forced to shut down or limit services. The AMA Litigation Center brief tells the court that “potential hospital closures would decrease access to all types of care, resulting in far worse health outcomes for the insured and uninsured alike.” 

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