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Medicaid work requirements struck down for NH, still pending for Alabama


On July 29 of this year, a federal judge struck down New Hampshire’s Medicaid work requirements. In 2018, Alabama proposed a Section 1115 Medicaid waiver to the federal government to institute similar work requirements. 

Alabama’s work requirements have yet to receive necessary federal approval to and have thus not been put into practice, unlike New Hampshire’s work requirements which were approved in 2018 prior to being struck down. 

U.S. District Judge James E. Boasberg called the policy “arbitrary and capricious,” in his ruling against the Secretary of Health and Human Services’ approval of the New Hampshire work requirements. But even before Boasberg’s ruling, New Hampshire officials had halted the implementation of work requirements after estimating that 17,000 would have lost their Medicaid coverage in August. The proposal required most non-disabled Medicaid recipients aged 19 to 64 to work, volunteer, participate in job training or be in school for at least 100 hours a month — or otherwise show they satisfy an exemption, like being pregnant or unable to work — or risk losing their health coverage.

In 2010, the Affordable Care Act was passed to increase the number of Americans covered by health insurance. States have the option to expand Medicaid to more low-income people under the law, with the federal government covering 100 percent — and later 90 percent — of the expense of expanding Medicaid to people earning up to 138 percent of the federal poverty line. In 2014, New Hampshire chose to expand Medicaid. 

Work requirements for Medicaid began when the Trump administration announced in 2018 that states could now tie Medicaid eligibility to work status using Section 1115 waivers, a practice which was not allowed during the Obama administration. As of July 30, six states had their work requirement proposals approved by the Centers for Medicare and Medicaid Services and another seven had pending proposals, according to the Kaiser Family Foundation. Three states — Arkansas, Kentucky and most recently New Hampshire — have had their work requirements set aside by federal courts. 

Alabama’s Section 1115 Medicaid waiver proposes a 35 hours per week requirement in “employment related activities” for parents or caretaker relatives or 20 hours per week for parent or caretaker relatives with a child under six years old. Exemptions are made for the disabled, medically frail, pregnant, elderly and others. The revised Section 1115 waiver from July of 2018 can be found here. A more recently revised version is currently unavailable on the state Medicaid website

Judging by time requirement, Alabama’s proposal is the most demanding to be submitted to the federal government.

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Alabama is also one of the 14 states to not have adopted Medicaid expansion. 

The people who could lose Medicaid coverage under Alabama’s proposed work requirements would be parents or close relatives of a child under age 19 in the home who has family income at or below 18 percent of the federal poverty level. As of January 2019, parents of a family of three must make less than $3,839 per year just to be eligible to receive Medicaid as a parent or caretaker relative. That is the second lowest Medicaid income limit in the country for parents or caretaker relatives.

However, the proposal does increase the transitional Medicaid period from six to eighteen months for those who are no longer eligible due to an increase in income.

Because Alabama never passed Medicaid expansion, it could mean that these Medicaid work requirements are less likely to get federal approval. Here’s why: When commenters said that some New Hampshire beneficiaries may lose coverage under the work requirements, Health and Human Services replied, saying, “the demonstration will provide coverage to individuals that the state is not required to cover” — which, as Boasberg points out, is the ACA expansion population. New Hampshire threatened to end its Medicaid coverage of many low-income individuals if its work requirements weren’t approved, and Alabama just doesn’t have that type of weight to push around.

Since the work requirements were struck down, New Hampshire has not dropped Medicaid for its ACA expansion population.


Evan Mealins is a reporting intern at the Alabama Political Reporter and student at Auburn University working toward a B.A. in media studies. You can follow him on Twitter @EvanMealins or email him at [email protected].

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