People With Mental Illness, SUDs Less Likely to Meet Medicaid Work Requirements

Several states have received waivers from the federal government allowing them to require Medicaid enrollees to work, look for a job, or engage in community service as a condition of maintaining coverage. Yet people with serious mental illness (SMI), substance use disorders (SUDs), or chronic health conditions—populations Medicaid is meant to help—are less likely to meet such requirements, say researchers in the April Health Affairs.

Johns Hopkins Bloomberg School of Public Health

Hefei Wen, Ph.D., an assistant professor of health management and policy at the University of Kentucky in Lexington, and colleagues analyzed data gathered between 2014 and 2016 by the National Survey on Drug Use and Health. The researchers then extracted a sample of 13,058 Medicaid enrollees aged 18 to 64 years. Their sample did not include people who were likely to be exempt from Medicaid work requirements, such as pregnant women, full-time students, and people who receive Social Security income.

The researchers found that those with SMI were less than half as likely to have worked at least 20 hours in the past week as those without any health conditions, meaning they would be less likely to meet Medicaid work requirements: Just 22.8% of Medicaid enrollees with SMI worked at least 20 hours in the previous week, compared with 49.2% of those with no identified conditions. Furthermore, 42.8% of those with SUDs and 32.3% of those with both SMI and SUDs worked at least 20 hours in the previous week. Medicaid enrollees with chronic health conditions were 9.4% less likely to have worked at least 20 hours in the previous week than those without identified conditions.

Some people in these populations may be exempt from the requirements, but they could still end up losing Medicaid coverage if proving that they qualify is too onerous or difficult, said Brendan Saloner, Ph.D., an assistant professor at Johns Hopkins Bloomberg School of Public Health in Baltimore and a researcher in the study.

“It comes down to how much paperwork is required of enrollees,” Saloner said. “In some states, the proposals would be to have individuals document their status on a website, but many people with serious cognitive and physical health challenges do not have access to a computer or know how to use the internet. Unless there are caseworkers or navigators who steer people through the documentation process, many people will get lost in the paperwork shuffle.”

To compound matters, those with SMI or SUDs who currently cannot work because of their conditions may lose access to the Medicaid-covered mental health services that can help them become work-ready.

“This paper confirms what most mental health professionals know: that a high proportion of our patients are reliant on Medicaid for insurance coverage and are unable to work and unable to access evidence-based programs like supported employment and other effective psychosocial treatments that would make it possible to work,” said Marvin Swartz, M.D., chair of APA’s Committee on Judicial Action, who was not involved in the research. “Absent these programs, Medicaid work requirements would have a devastating effect on our patients. Imposing a work requirement effectively would blame the victims for the failures of our publicly sponsored behavioral health systems.”

Saloner urged psychiatrists to speak out and provide insight to legislators.

“Mental health providers are an important voice in the process, and they can help educate their patients about new Medicaid policies and be active in advocacy through the notice-and-comment process. In addition to the quantitative data that our study provides, real patient stories are an important piece of evidence to influence policy decisions,” Saloner said.

This study was supported in part by Saloner’s early career award from the National Institute on Drug Abuse.  ■