Today 172 House Democrats sent a letter to Secretary of Health and Human Services (HHS) Alex Azar expressing their unified opposition to the Trump Administration’s actions that will allow, for the first time in the history of the Medicaid program, a work requirement as a condition of coverage. The House Democrats are deeply concerned that linking health coverage to a work requirement will undermine access to health care, and contradict the plain text and purpose of the law.
The letter comes after the Centers for Medicare and Medicaid Services (CMS) announced last month that the agency would allow states to require a person to work in order to have access to Medicaid. One day later, CMS gave unprecedented approval to a so-called Section 1115 waiver request from Kentucky allowing it to include work requirements for Medicaid coverage. CMS has also approved a work requirement waiver for Indiana. These types of requirements have routinely been deemed by previous administrations as unlawful.
“Medicaid demonstrations that adopt restrictive conditions on eligibility like work requirements, mandatory drug testing, lock-out periods, coverage time limits, disenrollment and onerous premiums and cost-sharing threaten to impede rightful access to care for Americans, a consequence that contravenes the statute and Congress’s longstanding intent in creating the Medicaid program," the 172 House Democrats wrote in their letter. “We urge you to faithfully administer the Medicaid Act and to reject and reconsider Section 1115 demonstration requests that jeopardize the health and financial security of Medicaid beneficiaries."
Congress intended for Section 1115 waivers to be issued by CMS to states to conduct projects that fundamentally advance Medicaid. Over 30 states have taken advantage of this flexibility by conducting demonstrations that improve health care access, coverage, or delivery.
In stark contrast, waivers like the one approved by the Trump Administration in Kentucky and Indiana undercut and exceed statutory authority given to the Secretary of HHS. The House Democrats wrote that CMS continues to take actions demonstrating the agency’s intent to approve demonstration waivers that the Democrats believe would bar eligible individuals from Medicaid through restrictive and onerous eligibility requirements.
“Such actions to tie health coverage to work are motivated purely on the basis of ideology and mistaken assumptions about what Medicaid is and who it covers," the House Democrats continued in their letter. “The reality is that CMS’s recent actions ignore a fundamental truth: most of those who can work, are working, but may fall through the cracks and lose their coverage due to harsh and inflexible implementation of this ideologically-driven policy."
Medicaid is a part of the lives of more than 70 million elderly, low-income, disabled adults and children that depend on the program to help provide them peace of mind and financial security to move their families out of poverty. The House Democrats wrote imposing such policies on Medicaid families, who are generally living on a budget of roughly less than $15,000 per year, is not only punitive but also counterproductive. At their core, policies such as work requirements assume that individuals should work in order to have good health, when the opposite is plainly true: good health is essential for successful employment.
Full text and signatories of the letter can be found below:
Feb. 14, 2018
The Honorable Alex M. Azar
Secretary
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Secretary Azar:
We write in opposition to the Administration’s actions that will allow, for the first time in the Medicaid program, a work requirement as a condition of coverage. We are deeply concerned that linking health coverage to a work requirement not only will undermine access to health care, but contradicts the plain text and purpose of Title XIX of the Social Security Act and Congress’s longstanding intent for the Medicaid program. We urge you to reconsider these actions, which are outside the boundaries of the statutory authority provided to you under the Medicaid Act.
Congress enacted Title XIX in 1965 with a clear statutory objective to provide (1) “medical assistance [to eligible individuals] whose income and resources are insufficient to meet the costs of necessary medical services" and (2) “rehabilitation and other services to help such families and individuals attain or retain capability for independence or self-care." To the extent Medicaid’s objectives mention “independence," that is explicitly in the context of helping low-income individuals, particularly those with disabilities, maximize their integration in their communities.
Section 1115 of the Social Security Act permits states to waive certain federal Medicaid requirements to conduct an “experimental, pilot, or demonstration project" that achieves the goals of the Medicaid program. Notably, Medicaid's existing flexibility has allowed states to find innovative ways to shape their programs to deliver quality care and protect consumers against health crises while lowering costs. Today, more than thirty states across the country have taken advantage of this flexibility by conducting demonstrations that, in line with the statute and CMS’s (Centers for Medicare and Medicaid Services) own stated principles, improve the coverage and delivery of health care services. States have used Section 1115 waiver authority to undertake innovative delivery system reform initiatives; for instance, tying provider incentive payments to performance goals and/or better integrating primary and behavioral health care. These types of projects indisputedly advance the health of Medicaid beneficiaries, in line with the text and purpose of the Medicaid Act, by improving the care beneficiaries receive and helping them to access quality health services.
In contrast to these demonstrations, waivers with ideologically driven policies such as work requirements, mandatory drug testing, lock-out periods, coverage time limits, onerous premiums, and cost-sharing not only undermine, but exceed the statutory authority provided to the Secretary under Section 1115 and contravene longstanding Congressional intent. Far from promoting health, these types of policies will make it difficult for families struggling to make ends meet to access the care they need and are entitled to under Title XIX. Ultimately, this leads to poorer health for individuals and difficulty in maintaining successful employment, costing the system more in the long run and negatively impacting the overall health of our communities. That is why past Democratic and Republican Administrations have resoundingly rejected these types of waiver requests on the basis that such provisions would not further the program’s statutory purposes of promoting health coverage and access.
Unfortunately, this Administration has chosen to take actions furthering these types of ideologically-based demonstrations. On Jan. 11, CMS issued a State Medicaid Director letter that advertised the agency’s intent to approve 1115 waivers that would condition an otherwise eligible individual’s medical assistance on unprecedented work requirements. On Jan. 12, CMS announced its approval of an amendment to Kentucky’s ongoing Section 1115 demonstration tying the receipt of medical assistance for otherwise eligible individuals to meeting burdensome work and other requirements. In the more than 50 years of the Medicaid program’s existence, this is the first time CMS has approved a state request to condition access to health care on work and related activities.
Such actions to tie health coverage to work are motivated purely on the basis of ideology and mistaken assumptions about what Medicaid is and who it covers. Medicaid is a part of the lives of more than 70 million elderly, low-income, disabled adults and children that depend on the program to help provide them piece of mind and financial security to move their families out of poverty. The reality is that CMS’s recent actions ignore a fundamental truth: most of those who can work, are working, but may fall through the cracks and lose their coverage due to harsh and inflexible implementation of this ideologically-driven policy.
Medicaid demonstrations that adopt restrictive conditions on eligibility like work requirements, mandatory drug testing, lock-out periods, coverage time limits, disenrollment, onerous premiums, and cost-sharing threaten to impede rightful access to care for Americans, a consequence that contravenes the statute and Congress’s longstanding intent in creating the Medicaid program. We urge you to faithfully administer the Medicaid Act and to reject and reconsider Section 1115 demonstration requests that jeopardize the health and financial security of Medicaid beneficiaries.
Sincerely,
Democratic Leader Nancy Pelosi
Democratic Whip Steny H. Hoyer
Assistant Democratic Leader James E. Clyburn
Democratic Caucus Chairman Joseph Crowley
Democratic Caucus Vice Chairman Linda Sánchez
Energy and Commerce Ranking Member Frank Pallone, Jr.
Energy and Commerce Subcommittee on Health Ranking Member Gene Green
Alma S. Adams (NC-12)
Pete Aguilar (CA-31)
Nanette Diaz Barragán (CA-44)
Karen Bass (CA-37)
Joyce Beatty (OH-03)
Ami Bera (CA-07)
Donald S. Beyer Jr. (VA-08)
Sanford D. Bishop Jr. (GA-02)
Earl Blumenauer (OR-03)
Lisa Blunt Rochester (DE-AL)
Suzanne Bonamici (OR-01)
Madeleine Z. Bordallo (GU-DL)
Brendan F. Boyle (PA-13)
Robert A. Brady (PA-01)
Anthony G. Brown (MD-04)
Julia Brownley (CA-26)
Cheri Bustos (IL-17)
G.K.Butterfield (NC-01)
Michael E. Capuano (MA-07)
Salud O. Carbajal (CA-24)
Tony Cárdenas (CA-29)
André Carson (IN-07)
Matt Cartwright (PA-17)
Kathy Castor (FL-14)
Joaquin Castro (TX-20)
Judy Chu (CA-27)
David N. Cicilline (RI-01)
Katherine M. Clark (MA-05)
Yvette D. Clarke (NY-09)
Wm. Lacy Clay (MO-01)
Emanuel Cleaver (MO-05)
Steve Cohen (TN-09)
Gerald E. Connolly (VA-11)
John Conyers Jr. (MI-13)
Joe Courtney (CT-02)
Elijah E. Cummings (MD-07)
Danny K. Davis (IL-07)
Susan A. Davis (CA-53)
Diana DeGette (CO-01)
John K. Delaney (MD-06)
Rosa L. DeLauro (CT-03)
Suzan K. DelBene (WA-01)
Val Butler Demings (FL-10)
Mark DeSaulnier (CA-11)
Theodore E. Deutch (FL-22)
Debbie Dingell (MI-12)
Michael F. Doyle (PA-14)
Keith Ellison (MN-05)
Eliot L. Engel (NY-16)
Anna G. Eshoo (CA-18)
Adriano Espaillat (NY-13)
Elizabeth H. Esty (CT-05)
Bill Foster (IL-11)
Lois Frankel (FL-21)
Marcia L. Fudge (OH-11)
Tulsi Gabbard (HI-02)
Ruben Gallego (AZ-07)
Vicente Gonzalez (TX-15)
Al Green (TX-09)
Raúl M. Grijalva (AZ-03)
Luis V. Gutiérrez (IL-04)
Colleen Hanabusa (HI-01)
Alcee L. Hastings (FL-20)
Denny Heck (WA-10)
Brian Higgins (NY-26)
Jared Huffman (CA-02)
Sheila Jackson Lee (TX-18)
Pramila Jayapal (WA-07)
Hakeem S. Jeffries (NY-08)
Eddie Bernice Johnson (TX-30)
Henry C. "Hank" Johnson Jr. (GA-04)
Marcy Kaptur (OH-09)
William R. Keating (MA-09)
Robin L. Kelly (IL-02)
Joseph P. Kennedy III (MA-04)
Ro Khanna (CA-17)
Ruben Kihuen (NV-04)
Daniel T. Kildee (MI-05)
Derek Kilmer (WA-06)
Raja Krishnamoorthi (IL-08)
James R. Langevin (RI-02)
Rick Larsen (WA-02)
John B. Larson (CT-01)
Brenda L. Lawrence (MI-14)
Al Lawson Jr. (FL-05)
Barbara Lee (CA-13)
Sander M. Levin (MI-09)
John Lewis (GA-05)
Ted Lieu (CA-33)
David Loebsack (IA-02)
Zoe Lofgren (CA-19)
Alan S. Lowenthal (CA-47)
Nita M. Lowey (NY-17)
Ben Ray Luján (NM-03)
Michelle Lujan Grisham (NM-01)
Carolyn B. Maloney (NY-12)
Sean Patrick Maloney (NY-18)
Doris O. Matsui (CA-06)
Betty McCollum (MN-04)
A. Donald McEachin (VA-04)
James P. McGovern (MA-02)
Jerry McNerney (CA-09)
Gregory W. Meeks (NY-05)
Grace Meng (NY-06)
Gwen Moore (WI-04)
Seth Moulton (MA-06)
Jerrold Nadler (NY-10)
Grace F. Napolitano (CA-32)
Richard E. Neal (MA-1)
Richard M. Nolan (MN-08)
Donald Norcross (NJ-01)
Eleanor Holmes Norton (DC-00)
Beto O'Rourke (TX-16)
Jimmy Panetta (CA-20)
Bill Pascrell Jr. (NJ-09)
Donald M. Payne Jr. (NJ-10)
Ed Perlmutter (CO-07)
Scott H. Peters (CA-52)
Chellie Pingree (ME-01)
Stacey E. Plaskett (VI-00)
Mark Pocan (WI-02)
Jared Polis (CO-02)
David E. Price (NC-04)
Mike Quigley (IL-05)
Jamie Raskin (MD-08)
Kathleen M. Rice (NY-04)
Cedric L. Richmond (LA-02)
Jacky Rosen (NV-03)
Lucille Roybal-Allard (CA-40)
Raul Ruiz (CA-36)
C.A. Dutch Ruppersberger (MD-02)
Bobby L. Rush (IL-01)
Gregorio Kilili Camacho Sablan (MP-00)
John P. Sarbanes (MD-03)
Janice D. Schakowsky (IL-09)
Adam B. Schiff (CA-28)
Bradley Scott Schneider (IL-10)
David Scott (GA-13)
Robert C. “Bobby" Scott (VA-3)
José E. Serrano (NY-15)
Terri A. Sewell (AL-07)
Brad Sherman (CA-30)
Albio Sires (NJ-08)
Louise McIntosh Slaughter (NY-25)
Darren Soto (FL-09)
Jackie Speier (CA-14)
Thomas R. Suozzi (NY-03)
Eric Swalwell (CA-15)
Mark Takano (CA-41)
Bennie G. Thompson (MS-02)
Mike Thompson (CA-05)
Dina Titus (NV-01)
Paul Tonko (NY-20)
Norma J. Torres (CA-35)
Niki Tsongas (MA-03)
Juan Vargas (CA-51)
Marc A. Veasey (TX-33)
Filemon Vela (TX-34)
Nydia M. Velázquez (NY-07)
Timothy J. Walz (MN-01)
Debbie Wasserman Schultz (FL-23)
Bonnie Watson Coleman (NJ-12)
Peter Welch (VT-AL)
Frederica S. Wilson (FL-24)
John A. Yarmuth (KY-3)
