Despite Mounting Evidence of Harm, New Hampshire Poised to Impose Harsh Medicaid Work Rules

With federal approval now in hand, New Hampshire appears poised to move forward with a new policy to take away Medicaid coverage from people not working or engaged in qualifying work activities for 100 hours per month — despite mounting evidence that it will lead thousands of residents to lose coverage, including working people and people with serious health needs.

On Friday, the Centers for Medicare & Medicaid Services (CMS) approved New Hampshire’s revised waiver proposal. The state revised its waiver to conform with a new state law that state policymakers enacted after CMS approved New Hampshire’s original proposal in May.

In Arkansas, the first state to implement Medicaid work requirements, over 12,000 beneficiaries have already lost Medicaid and likely become uninsured in just the first six months. In fact, the number of Arkansans losing Medicaid coverage exceeds the policy’s presumed target population — namely, people who are neither working nor qualify for an exemption — so working people and people who should be eligible for exemptions are almost certainly losing Medicaid. News accounts confirm that the policy is having severe unintended consequences — including working people losing their jobs because they fail to meet complex reporting requirements, in turn losing their Medicaid, and then being unable to get treatment for chronic conditions that’s necessary for them to work.

The large coverage losses in Arkansas led the nonpartisan Medicaid and CHIP Payment and Access Commission (MACPAC), charged with advising Congress and the Executive Branch on Medicaid and CHIP policy, to call on the Department of Health and Human Services (HHS, where CMS is housed) to pause the disenrollments. Most beneficiaries’ failure to satisfy the new rules “is a strong warning signal that the current process may not be structured in a way that provides individuals an opportunity to succeed, with high stakes for beneficiaries who fail,” MACPAC warned. MACPAC also advised HHS not to approve other states’ work requirement proposals until the agency has “establish[ed] mechanisms for effective monitoring and ensur[ed] adequate lead time for implementation.”

Yet the New Hampshire policy that the Administration just approved is even harsher than Arkansas’, in several ways:

• Its 100-hour threshold exceeds the 80 hours that Arkansas and most other states proposing these policies require.
• It applies to adults up to age 64, versus 49 in Arkansas; older adults are less likely to be working, in part because they’re likelier to face serious health challenges.
• It applies to parents of children age 6 and older, whereas Arkansas’ policy excludes parents. Eliminating parents’ coverage harms children because families lose financial security and parents are less able to take care of their own physical and mental health. Studies also find that children are likelier to have health coverage when their parents do, too: children’s coverage and access to care both improved as states expanded Medicaid coverage for parents.

Also, the policy CMS approved goes beyond New Hampshire’s revised waiver application in that, starting in May 2020, it doesn’t allow beneficiaries to maintain their coverage if they need more than one month to make up missed hours from a previous month.

As we’ve explained, many of those who will likely lose coverage due to New Hampshire’s waiver will be working people who can’t meet the 100-hour requirement every month, and others who should be exempt but can’t overcome the red tape to prove it. Research shows that families sanctioned due to non-compliance with work requirements under the Temporary Assistance for Needy Families (TANF) program are likelier than other families receiving TANF to have barriers that keep them from working and that should exempt them from the requirements, such as having a child with a chronic illness or disability.

Since New Hampshire adopted the Affordable Care Act’s Medicaid expansion, its uninsured rate has fallen by 45 percent, and the share of adults forgoing care due to costs has fallen by about a quarter. Medicaid is now an important source of coverage for over 52,000 low-income adults in New Hampshire, providing cervical, breast, and colorectal cancer screenings to over 20,000 adults and substance use disorder services — which are critical in combatting the opioid epidemic gripping the state — to 11,000 adults. And uncompensated care costs have fallen by about half as a share of hospital budgets since expansion took effect. New Hampshire should reconsider moving forward with its harmful changes or risk joining Arkansas in seeing thousands of low-income adults lose coverage, reversing the state’s recent progress.