Unfortunately, our series of reports looking at harmful state Medicaid work requirement rules targeting very poor parents is getting longer. Today we are releasing an updated look at Oklahoma’s proposal, which is currently up for public comment at the federal level. Six states now have active proposals – Mississippi, Alabama, and South Dakota have proposals waiting for a CMS decision, Tennessee and Oklahoma have proposals up for federal public comment, and South Carolina’s proposal is currently up for state public comment.
Oklahoma is seeking federal permission to impose a work requirement on very low-income parents and caregivers age 19-50 receiving health coverage through Medicaid. Parents of children below 6 are exempt. Under the proposal, which would be phased in, these beneficiaries would have to document that they are working at least 20 hours a week or participating in job-training or volunteer activities or lose their SoonerCare coverage. Because Oklahoma has not expanded Medicaid under the Affordable Care Act, the only adults affected are parents whose incomes are at or below 45 percent of the federal poverty level. The impact of the Oklahoma Health Care Authority’s proposed could mean some of the state’s poorest parents would lose health coverage altogether. And that loss of coverage will affect their children, who may lose coverage, as well.
Oklahoma’s proposal does not show any impact on enrollment. It is clear, however, from research based on the experience of work reporting rules in other programs and states that significant coverage losses are likely. Nationally, an analysis by the Kaiser Family Foundation projected that 6 to 17 percent of adults in the affected population would lose Medicaid coverage. Applying this range to Oklahoma’s parent population, an estimated 4,440 to 12,580 parents could lose coverage.[i] Some of these adults are already working and meet the requirements, but would lose access to health care because of administrative burdens or red tape. Our estimate may be conservative, because in Arkansas, the first state to implement a Medicaid work requirement, approximately 22 percent of those impacted have lost coverage. Moreover, less than 1% of those impacted in Arkansas are newly reporting work hours, suggesting the policy is clearly failing to achieve its purported objective.
The state received over 1,200 public comments on the proposal during the required state public comment process. The vast majority of these comments—over 95%–appear to have been submitted in opposition to the state’s plans, yet they were largely ignored.[ii]
The state cites a telephone survey it conducted of those subject to the new requirement and the barriers they face.[iii] The state was unable to contact almost 50% of those that it attempted to call due to a disconnected or unsuccessful call. This suggests that (similar to what has happened in Arkansas) many of those impacted by the policy will be hard to reach and may lose their health insurance as a result of new reporting requirements – not because they aren’t working but because the state can’t find them.
As is the case elsewhere, the proposal will mostly affect mothers and will disproportionately harm families living in rural areas and small towns. As we have noted before, children will be harmed when their parents become uninsured. The whole family is exposed to additional economic insecurity, and children are likely to go uninsured as well.
This is especially troubling in Oklahoma, since Oklahoma’s rate of uninsured children at 8.1 percent is already one of the highest in the nation, far above the 5.0 percent national average. The state ranks 48th for rate of uninsured children and Oklahoma is one of nine states to show a significant increase in its rate of uninsured children in 2017. If enacted, the state’s waiver amendment will likely exacerbate this damaging trend.
[i]Parent monthly enrollment of 73, 986 taken from “Sooner Care Fast Facts”, Oklahoma Health Care Authority, November 2018. We rounded that number to 74,000 and applied the 6 to 17 percent coverage loss range from Garfield, Rachel, Robin Rudowitz and MaryBeth Musumeci. “Implications of a Medicaid Work Requirement: National Estimates of Potential Coverage Losses.” (Washington: Kaiser Family Foundation, June 2018) accessed at https://www.kff.org/medicaid/issue-brief/implications-of-a-medicaid-work-requirement-national-estimates-of-potential-coverage-losses/
[ii] See Attachment C Public Comment Summary SoonerCare 1115(a) Amendment Request, 12/7/18. The state notes that just 23 of the more than 1,200 comments submitted were in support.
[iii] Ibid, p. 23-4.