A federal proposal to impose a work requirement on Medicaid recipients could have far-reaching consequences for North Carolinians who rely on the government-funded health insurance program.
The Republican-backed measure in Congress, which was part of the budget reconciliation bill passed last month by the U.S. House of Representatives, along with legislation introduced by the Senate Finance Committee on June 16, would require adult beneficiaries to prove that they work, volunteer or attend school for at least 80 hours a month.
Enrollees who fail to meet the requirement would lose coverage.
Both bills include exemptions for seniors, pregnant women and people with disabilities, but the version released by the Senate Finance Committee is stricter than what had originally been proposed by the House. That version extends the requirement to parents with children over the age of 14, a group that was previously excluded.
Critics say the requirement would result in an untold number of beneficiaries losing coverage — not due to unemployment, but paperwork issues.
“If you are of the belief, like I am, that Medicaid’s purpose is to get you healthy so that maybe you can work, and you already understand that a lot of people who can work already are working if they have Medicaid, then work requirements are just an additional barrier,” Ciara Zachary, an assistant professor at the University of North Carolina’s Gillings School of Global Public Health said in an interview earlier this year with NC Health News. “It’s not something that helps people’s health, and it’s certainly not going to get more people in the workplace in jobs that help them thrive.”
Indeed, researchers at the school estimate that about half of the state’s Medicaid-covered adults are either already working or actively looking for work. Many others are “experiencing conditions that make it challenging to find or keep a job,” according to researchers.
Tight income levels in traditional Medicaid
Until recently, the Medicaid program was really focused on people who had limitations around their ability to work. Medicaid head Jay Ludlam told lawmakers in February that nearly 4 in 5 beneficiaries are children and their family members.
Susie Gurzenda, a Ph.D. student at Gillings School of Global Public Health, shared findings about the ability of the adults in this “traditional” Medicaid population to work in a presentation during a Medicaid-themed symposium in Raleigh on May 30.
Gurzenda and her colleagues examined the workplace status of beneficiaries, ages 19 to 64, using data from 2023.
In this Medicaid population, most people were subject to an annual income cap of about $21,150 for a family of two in order to qualify and — depending on the reason that people qualified for the program — sometimes less. Some beneficiaries were eligible for Medicaid because they were parents of children on the program and were able to earn a little more.
Of this total population, 27 percent of the adult enrollees had full-time jobs, while 15 percent were working part-time.
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NC Health News
Gurzenda said 44 percent of these working-age adults were either unable to work or facing barriers to employment, including being people with disabilities (26 percent), parents with young children (10 percent) and students (5 percent).
The most common jobs among these working beneficiaries were in the retail (18 percent), hospitality (17 percent) and health care (12 percent) sectors. However, Gurzenda noted that employed recipients participated “in a wide variety of industries across the state,” including child care (5 percent) and educational services (5 percent).
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NC Health News
A number of people on the traditional Medicaid program are unable to work, including people with disabilities and older, low-income people who primarily live in nursing homes. Members of those groups make up about 21 percent of beneficiaries covered under the “traditional” program, Ludlam told state lawmakers this winter.
He explained that members of those two groups — who often have complex health problems — account for a large part of the spending on North Carolina Medicaid.
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NC Health News
Expansion changes program demographics
These numbers were rearranged once Medicaid expansion took effect in December 2023.
Expansion raised the annual income cap for the program to $29,187 for a family of two, which allowed more than 663,500 eligible residents to enroll for the first time. By design, most of these beneficiaries are people with low-wage jobs who nonetheless had made too much money to qualify.
In an email to NC Health News, a spokesperson for the N.C. Department of Health and Human Services said an estimated 92 percent of the state’s 1.6 million adult enrollees — a figure that includes traditional Medicaid enrollees and the expansion population — “are working individuals or are care giving, too disabled to work or may be in school.”
Paperwork could result in hurdles
While many of the state’s Medicaid recipients are already working, NC DHHS warned that as many as 255,000 North Carolinians are at risk of losing coverage if a work requirement is implemented.
About 213,000 of these at-risk enrollees, or 83 percent, only recently gained coverage through expansion, the agency said.
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NC Health News
People with limited internet access or who lack digital literacy may end up struggling to submit the required paperwork online, while language barriers and transportation issues can make in-person reporting just as difficult, according to a report from the Commonwealth Fund published earlier this year. These obstacles mean that even enrollees who meet the 80-hour-per-month threshold requirement could fall through the cracks.
The North Carolina Community Health Center Association, which represents more than 600 clinics across 92 counties, estimates that 89,000 of patients attending these clinics could be kicked off of Medicaid if the requirement moves forward.
“The data show that even North Carolinians who are working or exempt from the requirements will still lose their Medicaid coverage under these proposals,” Chris Shank, president and CEO of the association, said in a statement. “The administrative burden on local Departments of Social Services — and on Medicaid enrollees alike — to meet new manual, paperwork requirements will result in tens of thousands of health center patients losing Medicaid coverage and becoming uninsured.”
Many DSS offices are already struggling to keep up with the program’s demands. Ten percent of all county social service positions dedicated to Medicaid are currently vacant, according to NC DHHS.
“The proposed work requirements would cause a strain on North Carolina’s county social services offices and a significant need for increased positions and funding,” the agency said.
State Sen. Kevin Corbin (R-Franklin) — a strong proponent of Medicaid expansion — played down the concerns in an interview with NC Health News. He noted that many people predicted the state would be overwhelmed by the launch of expansion, which ultimately went “smoothly.”
“I can’t imagine that someone would not be able to fill out a paper or do something to be compliant,” Corbin said. “If everyone just simply had to answer what they were doing, as far as work or looking for work or whatever, then they just need to do that if that’s the requirement.
Females predominate
Supporters of the work requirement have framed the measure as a push toward self-sufficiency, with House Speaker Mike Johnson saying it will encourage “29-year-old males sitting on their couches playing video games” to seek gainful employment.
But the majority of North Carolina Medicaid beneficiaries are women, according to program statistics that show that nearly 56 percent of all enrollees are female.
Women make up an even larger share of the state’s enrollment among young adults. About 65 percent of beneficiaries between the ages of 21 and 45 are female, according to data from NC DHHS.
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NC Health News
Some Congressional Republicans have promoted the work requirement as a way to root out undocumented immigrants who are enrolled in Medicaid.
Among them is U.S. Rep. Richard Hudson (R-NC 9), who serves on the House committee that oversees the program. In April, he told constituents that his goal was to find out “how many illegals are on Medicaid” and “stop giving them the benefits.”
But undocumented immigrants do not qualify for full Medicaid coverage, at least not in North Carolina.
While some non-U.S. citizens residing in the state can enroll, eligibility is generally limited to refugees, asylees and victims of human trafficking. These lawfully present immigrants make up just 2 percent of the state’s enrollment.
On occasion, an undocumented person will receive Medicaid if they’ve had a catastrophic event and land in the hospital. As of June, the state recorded that 61 people qualified for this emergency coverage.
This article first appeared on North Carolina Health News and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.
North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.
