P&P April Issue 2018

have diverse opinions on how best to accomplish the goal of getting more nonworking, nondisabled adults into strong work preparatory programs or directly into a job. States generally believe that work requirements send a strong signal to such recipients that there is an expectation of reciprocity for clients to be active stewards in partnership with the agency to seek employment as a first step toward self- sufficiency. Without this mutual effort clients will not succeed on the proper path to getting and retaining a job. The important qualifiers for success in this shared goal include a number of factors. To assist clients who have limited work history and often face difficulties with one or more problems, including child care, transportation, meeting parental responsibilities, child support obligations, previous incarceration, chronic health condi- tions, among others, requires adequate funding and innovative approaches. Funding is critical to conduct proper assessments and assign clients to appropriate activities such as educa- tion and sector-based training aligned with available local labor market jobs. Building employer networks with businesses willing to hire adults with limited skills and experience and provide on-the job training through apprenticeships, subsidized employ- ment, and other skill development is key. Funds are also critical to actual job placement and helping clients navigate problems both before and after getting a job. This has not been the case in either TANF or SNAP, where additional—not less—funding, and increased flexibility rather than ill-designed federally prescriptive measures will be needed for success. Expanding work requirements to other programs will also be very resource dependent, if the goal is truly to get clients into jobs instead of simply imposing sanctions. States also feel that federal work requirements in existing programs like TANF and SNAP are too restrictive and that lessons learned about necessary changes will be instructive in efforts to expand to other programs. TANF and

has “effectively rewritten the statute... overturning a half-century of admin- istrative practice, and threatening irreparable harm to the health and welfare of the poorest and most vul- nerable in our country.” Depending upon the outcome, states could spend both time and money designing programs that are subsequently not allowed. There is a significant overlap of eligible populations already covered by TANF and SNAP E&T work rules, even more so if SNAP rules are greatly expanded and become mandatory. This could lead to confusion and duplicative engagement requirements. States also may currently lack systems and infra- structure to track clients assigned to activities or to enforce requirements. The CMS guidance on 1115 waivers offers broad options of allowable engagement activities, as do pro- posals in public housing. Still, it will be critical for states in their program design, CMS in its evaluation and approval of waivers, and the U.S. Department of Housing and Urban Development in reviewing expanded housing authority work require- ments, to only approve the types of activities most likely to lead to positive outcomes for clients. If approved proposals include compliance require- ments that block beneficiaries from access to health care or housing, the results could lead to increasing health problems, potential homelessness, and drive up the cost of both charity care in health and shelter costs in housing. In Medicaid, one approach that would be allowable and, perhaps, pro- ductive would be required enrollment for patients with chronic diseases in prevention and management programs that address obesity, diabetes, coronary disease, smoking cessation, and other health and wellness activi- ties. Limited efforts are underway in this area providing both incentives and limited sanctions and could be expanded. 8 Conclusion Member states in APHSA share a belief that gainful, sustainable employment is the best avenue out of social isolation and poverty and improves individuals’ health, but often

expense. Encouraging work is a rea- sonable goal for the program, as it has been in other programs such as TANF and SNAP. In fact, some early evidence suggests that Medicaid expansion has helped some individuals gain and sustain employment. 6 The nation’s economy has recovered from years of sluggishness and the unemployment rate is at a significantly low level. Yet employers need qualified workers and, in many sectors, cannot find them. This leads to an opportu- nity for states to ramp up their efforts across health and human services programs to train, skill-up, and place nonworking, nondisabled adults into jobs by working in close partnership with employers, both for- and not-for- profit organizational partners and the work-capable clients themselves, to accomplish this goal. In Medicaid particularly, where this approach is untested, allowing work/ community engagement requirements as a state option rather than compul- sory, as they are in TANF and SNAP, is important. States know their caseload, their health care systems, and their local job markets and are best suited to decide if they wish to add required activities as a condition of eligibility and how to design compliance rules. A number of policymakers claim that allowing states the option to require some level of engagement in return for Medicaid benefits may lead to further eligibility expansion in states that have not previously expanded Medicaid as allowed under the Affordable Care Act. Cautions About Expanding Work Requirements In Medicaid there is a serious question as to whether allowing states to impose work or other engagement requirements through the Section 1115 waiver process is legal. Some contend that doing so exceeds the HHS secretary’s authority by creating new eligibility requirements that do not further the goals of the program to help eligible people get medical services. There is also a question of whether these requirements could violate provisions of the Americans with Disabilities Act. 7 A class action lawsuit challenges the Kentucky waiver, asserting that it

See Work Requirements on page 35

April 2018   Policy&Practice 23