Penn experts call for safeguards if Medicaid work requirement policies prevail

May 09, 2018

PHILADELPHIA -- When the Centers for Medicare and Medicaid Services (CMS) announced controversial policies inviting states to establish work requirements as a condition to receive Medicaid, many in the medical community opposed it. Groups like the American Academy of Family Physicians and the American Psychiatric Association said the policies would create considerable health risks and financial harm among vulnerable populations and be at odds with efforts to address some of the country's biggest public health issues, like the opioid crisis.

If these measures continue to be approved - as is the case in Kentucky, Indiana, and Arkansas - CMS should act to minimize the potential harms they could cause to Medicaid recipients, two Penn Medicine experts in law and ethics argue in a new JAMA Viewpoint published this week, that lays out basic safeguards to help guide the states. "Promoting health, after all," the authors note, "is the goal of Medicaid."

"Not only do they raise ethical concerns, but policies that proponents say promote personal responsibility have a spotty record. And we know that losing insurance, which many could face, leads to significant harms to health, especially in lower-income individuals with chronic conditions," said Harald Schmidt, PhD, an assistant professor of Medical Ethics and Health Policy in the Perelman School of Medicine at the University of Pennsylvania. "Since the policies may survive legal challenges and move toward implementation, it's important that CMS provides guidance for states so they can be implemented with great care and the focus remains on protecting beneficiaries."

Schmidt penned the piece with co-author Allison K. Hoffman, a professor of Law at the University of Pennsylvania and an expert in health care law and policy at Penn's Leonard Davis Institute of Health Economics.

In the fall of 2017, CMS invited proposals from states that encourage personal responsibility and work requirements as incentives for beneficiaries to use fewer services and to transition to private insurance. According to CMS, such programs will "promote better mental, physical, and emotional health" and "help individuals and families rise out of poverty and attain independence."

More than 70 million low-income people in the United States are on Medicaid; however, any new policies would only apply to those who are not pregnant, elderly, or disabled. Work requirements have attracted the most attention, but other initiatives push to have beneficiaries confirm eligibility annually, pay premiums on time, and not use the emergency department for nonemergency care, and raise many of the same issues.

First, the authors propose, CMS and the states should continuously evaluate the feasibility of meeting new conditions and to protect people from disproportionate penalties, like eliminating benefits for first time infractions. Some states are offering alternatives to work requirements, like community service, which might seem accommodating, but evidence suggests that it may not be sufficient for recipients who face complex and challenging situations, the authors wrote. They believe that before CMS and the states suspend or terminate benefits, they should seek to understand why recipients have failed and provide support systems to help them.

High-risk subgroups, such as people battling chronic disease, drug addiction, or mental illness, should also receive health worker support or be exempt from the requirements altogether. Physicians treating beneficiaries who don't meet the requirements and no longer maintain coverage, the authors said, should also be able to request exemptions so they can continue to provide critical care when necessary and prevent a shift in care to Emergency Departments.

The authors propose that CMS and the states should monitor the health of those who have lost Medicaid benefits and later present in the emergency department, as well as stipulate when harms to beneficiaries rise to a level that requires state program changes or termination.

Finally, CMS should ensure openness and transparency by making all applications and evaluations publicly available online, similar to the information listed on, and be subject to formal, external peer review. This would enable key stakeholders to comment on the adequacy of study design and to monitor harms to participants, the authors wrote.

These safeguards are the first steps in a better direction if these policies continue to come into play across the country, Schmidt said. "Otherwise, [these requirements] look like little more than a tool for ideological social welfare cuts based on arbitrary determinations of who is deserving or underserving of receiving benefits that programs like Medicaid provide," the authors wrote.
Penn Medicine is one of the world's leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System, which together form a $7.8 billion enterprise.

The Perelman School of Medicine has been ranked among the top medical schools in the United States for more than 20 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $405 million awarded in the 2017 fiscal year.

The University of Pennsylvania Health System's patient care facilities include: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center -- which are recognized as one of the nation's top "Honor Roll" hospitals by U.S. News & World Report -- Chester County Hospital; Lancaster General Health; Penn Medicine Princeton Health; Penn Wissahickon Hospice; and Pennsylvania Hospital - the nation's first hospital, founded in 1751. Additional affiliated inpatient care facilities and services throughout the Philadelphia region include Good Shepherd Penn Partners, a partnership between Good Shepherd Rehabilitation Network and Penn Medicine, and Princeton House Behavioral Health, a leading provider of highly skilled and compassionate behavioral healthcare.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2017, Penn Medicine provided $500 million to benefit our community.

University of Pennsylvania School of Medicine

Related Emergency Department Articles from Brightsurf:

Deep learning in the emergency department
Harnessing the power of deep learning leads to better predictions of patient admissions and flow in emergency departments

Checklist for emergency department team's COVID-19 surge
After reviewing the literature on COVID-19 scientific publications the authors developed a checklist to guide emergency departments.

Why is appendicitis not always diagnosed in the emergency department?
A new study examines the factors associated with a potentially missed diagnosis of appendicitis in children and adults in the emergency department.

Providing contraceptive care in the pediatric emergency department
A new study found that two-thirds of female adolescents ages 16-21 seen in a pediatric Emergency Department (ED) were interested in discussing contraception, despite having a high rate of recent visits to a primary care provider.

Low back pain accounts for a third of new emergency department imaging in the US
The use of imaging for the initial evaluation of patients with low back pain in the emergency department (ED) continues to occur at a high rate -- one in three new emergency visits for low back pain in the United States -- according to the American Journal of Roentgenology (AJR).

Emergency department admissions of children for sexual abuse
This study analyzed emergency department admissions of children for sexual abuse between 2010 and 2016 using a nationwide database of emergency visits and US Census Bureau data.

30-day death rates after emergency department visits
Researchers used Medicare data from 2009 to 2016 to see how 30-day death rates associated with emergency department visits have changed.

Preventing smoking -- evidence from urban emergency department patients
A new study from the Prevention Research Center of the Pacific Institute for Research and Evaluation offers a more in-depth understanding of smoking among patients in an urban emergency department.

When a freestanding emergency department comes to town, costs go up
Rather than functioning as substitutes for hospital-based emergency departments, freestanding emergency departments have increased local market spending on emergency care in three of four states' markets where they have entered, according to a new paper by experts at Rice University.

Emoji buttons gauge emergency department sentiments in real time
Simple button terminals stationed around emergency departments featuring 'emoji' reflecting a range of emotions are effective in monitoring doctor and patient sentiments in real time.

Read More: Emergency Department News and Emergency Department Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to