Assessment of Health Status and Barriers to Employment Among Medicaid Beneficiaries Not Meeting Work Requirements After Accounting for State Medical Frailty Exemptions

Abstract

This cross-sectional study quantifies the proportion of nonexempt Medicaid beneficiaries not meeting work requirements, compares their health with nonexempt beneficiaries fulfilling requirements, and assesses their inability to work for health-related reasons.

As of February 2020, 28 states have sought or received US Centers for Medicare & Medicaid Services approval to impose work requirements as a condition of Medicaid eligibility.¹ Centers for Medicare & Medicaid Services requires states to exempt medically frail Medicaid beneficiaries from work requirements^2,3 but gives states flexibility in defining such exemptions. After accounting for state definitions of medical frailty exemptions, it is uncertain whether nonexempt beneficiaries not meeting work requirements are disproportionately ill or medically unable to work.^4,5 We characterized the proportion of nonexempt beneficiaries not meeting work requirements and determined whether they (1) differ in health from beneficiaries fulfilling them and (2) do not meet the requirements for health-related reasons.

Methods

We conducted a cross-sectional analysis using the Agency for Healthcare Research and Quality 2014 and 2015 Medical Expenditure Panel Survey (MEPS) Household Component, an annual nationally representative household survey. We used the demographic, labor, and health-related data in MEPS to model Medicaid work requirement criteria, including medical frailty. As we had insufficient data for individual states, we modeled work requirements nationally across all Medicaid beneficiary respondents. We conducted 4 parallel analyses, varying only the medical frailty exemption criteria used in each analysis. Given the nature of the data set, institutional review board approval was waived. This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline.

For each analysis, we first excluded beneficiaries who are commonly exempted in all proposed state work requirement plans: those 17 years or younger, 65 years or older, pregnant, categorized as disabled on Supplemental Security Income, full-time students, primary caretakers of dependents younger than 6 years, or dually enrolled in Medicare. Next, we excluded medically frail beneficiaries—also exempt—using medical frailty designation methods from one of 4 states with clear, publicly described methods that could be modeled within MEPS: Arkansas, Indiana, Michigan, and New Hampshire (eAppendix in the Supplement). Finally, using weekly work hours reported in MEPS, we classified remaining nonexempt beneficiaries as either fulfilling (working 20 or more hours per week) or not meeting (working less than 20 hours per week) the 20-hour workweek requirement proposed by 90% of states.¹

Using logistic regression adjusting for income, we compared the adjusted prevalence of self-reported fair or poor general or mental health among beneficiaries fulfilling and not meeting work requirements (eAppendix in the Supplement). Among beneficiaries not meeting work requirements, we estimated the proportion who self-reported the inability to work owing to illness or disability despite previous employment. We used Stata/SE version 14.0 (StataCorp), weighting all proportions accounting for MEPS survey design.

Results

Among 20 508 respondents representing 59 908 525 Medicaid beneficiaries nationwide in 2014 and 2015, 54 323 166 (75.7%) met the common work requirement exemptions. Depending on the state medical frailty exemption definition used, an additional 1.2% to 2.9% of beneficiaries who did not meet the common work requirement exemptions met state medical frailty exemptions. Of the remaining 21.4% to 23.1% of nonexempt beneficiaries (ie, those subject to work requirements), 10.2% to 10.6% fulfilled work requirements and 11.1% to 12.6% did not meet them (Figure 1).

Figure 1. Proportion of Medicaid Beneficiaries Exempt From, Fulfilling, or Not Meeting Work Requirements (WR).

Results are from 20 508 respondents from the 2014 and 2015 Medical Expenditure Panel Survey Household Component, representing 59 908 525 Medicaid beneficiaries. Common exemptions included age of 17 years or younger or 65 years or older, pregnancy, categorization as disabled on Supplemental Security Income, full-time enrollment in school, serving as primary caretakers for children younger than 6 years, or dual enrollment in Medicare. Fulfilling or not meeting WR is based on a 20-hour weekly workhour requirement. Error bars indicate 95% CIs.

Among nonexempt beneficiaries, those not meeting work requirements had significantly poorer general and mental health than those fulfilling them (Figure 2A and B). Controlling for income, 20.3% to 26.3% of beneficiaries not meeting work requirements reported fair or poor general health compared with 13.5% to 14.3% of beneficiaries fulfilling work requirements, and 15.5% to 19.6% of those not meeting work requirements reported fair or poor mental health compared with 6.0% to 7.3% of those fulfilling work requirements. Among beneficiaries not meeting work requirements, 15.4% to 19.6% reported an inability to work for health-related reasons (Figure 2C).

Figure 2. Health-Related Outcomes Among Medicaid Beneficiaries Fulfilling or Not Meeting Work Requirements (WR).

Results are from 3943 (Arkansas), 4156 (Indiana), 4075 (Michigan), and 4242 (New Hampshire) respondents from the 2014 and 2015 Medical Expenditure Panel Survey Household Component, representing 6 222 583 (Arkansas), 6 266 553 (Indiana), 6 119 818 (Michigan), and 6 332 517 (New Hampshire) Medicaid beneficiaries fulfilling WR and 6 653 944 (Arkansas), 7 287 551 (Indiana), 7 191 469 (Michigan), and 7 549 510 (New Hampshire) beneficiaries not meeting WR. Percentages of beneficiaries reporting fair or poor general or mental health are adjusted for beneficiary family income as a percentage of the federal poverty level. Fulfilling (working 20 or more hours per week) or not meeting (working less than 20 hours per week) WR is determined after exempting beneficiaries who are 17 years or younger, 65 years or older, pregnant, categorized as disabled on Supplemental Security Income, enrolled full-time in school, serving as primary caretakers for children younger than 6 years, or also enrolled in Medicare. Error bars indicate 95% CIs.

Discussion

Among Medicaid beneficiaries subject to work requirements, those not meeting them were disproportionately sicker than those fulfilling them and often reported health-related barriers to work. Our findings suggest that state medical frailty definitions for Medicaid beneficiaries may incompletely identify medical inability to work.

Our analysis has limitations. The outcome measures, although widely used and valid health and labor status indicators, were self-reported. We analyzed Medicaid beneficiaries nationwide; results may differ state by state.⁶ Our estimates may be conservative; MEPS lacks some work requirement criteria variables (eg, job training), so we may have overclassified healthy underemployed beneficiaries as not meeting requirements and thereby underestimated fair or poor health in this group of beneficiaries. Similarly, we likely underestimated health-related inability to work, since MEPS limits this question to previously employed respondents. Additionally, our study is cross-sectional and cannot establish causality. These limitations notwithstanding, our findings suggest that Medicaid work requirements may lead some beneficiaries not meeting common work requirement and medical frailty exemptions to lose health insurance coverage because of underlying illness and an inability to work.

Supplement.

eAppendix.