Iowans frustrated, concerned over Medicaid work requirements proposal

URBANDALE — Heather Sanders said her 92-year-old mother has been in and out of the hospital 14 times in the last four years.

“I’ve slept very little the last three months because of one hospital after another,” Sanders said.

The 54-year-old quit her teaching job with Ankeny Community School District to focus on providing full-time, at-home care for her elderly mother. Sanders said she has struggled to find work that can accommodate her caregiving responsibilities.

“I have tried to get at-home jobs,” Sanders said. “Nobody will hire me at the age of 54. I have tried everything. I've even tried to pay somebody to babysit her while I also work.”

Sanders said that even with a master’s degree, she is unable to find suitable work.

“We're competing with 23-year-olds that have more qualifications than me, and they're getting the jobs,” she said. “And I'm not getting one because I'm older, and yet I'm working my A off to help my mom and try to find something.”

Now, she worries about losing her state-funded Medicaid health coverage under Iowa’s request for a federal waiver that would allow the state to require most able-bodied Iowa Medicaid patients to work at least 100 hours per month as a condition of receiving coverage.

Republican Gov. Kim Reynolds earlier this month directed the Iowa Department of Health and Human Services to submit the waiver request to the U.S. Centers for Medicare and Medicaid Services. The waiver request is similar to legislation being advanced by Republican state lawmakers.

  Buy Photo

“It has always been a priority of mine to make sure our government programs reflect a culture of work. It is common sense and good policy,” Reynolds said in a statement. “If you are an able-bodied adult who can work, you should work. We need to return Medicaid back to its core purpose — to provide coverage to the people who truly need it.”

The department held a public hearing Wednesday on the state’s intentions to request federal approval to establish work and reporting requirements as a condition of maintaining eligibility in the Iowa Health and Wellness Plan, Iowa's Medicaid expansion program for low-income adults.

  Buy Photo

Iowa in 2013 expanded its Medicaid coverage to include individuals up to 133 percent of the federal poverty level, up from the previous threshold of 100 percent.

An individual at 133 percent of the federal poverty level makes $20,815 annually; a family of three at that level makes $35,445.

Approximately 171,000 able-bodied adults are enrolled in Iowa’s Medicaid program through the Iowa Health and Wellness plan.

CMS procedure requires Iowa HHS to conduct a 30-day public comment period and to host two public hearings on the proposed waiver.

About 40 people gathered at the Urbandale public library to asks questions and voice concerns over the Medicaid work and reporting requirements.

  Buy Photo

Sanders was among more than a dozen speakers who expressed concerns about the impact on caregivers, individuals with disabilities, and those with mental health challenges.

“Nobody will hire me,” she said. “… So what are we supposed to do? I think the state should have to help us find the job if we can't get hired, and we're trying our best.”

Several speakers asked the state to provide more clarity on the process for determining disability status and the appeals process for those who are denied exemptions. Others also inquired as to what data or evidence was used to determine the appropriate exemption criteria, and how the state will monitor the impact on health care access and outcomes.

Nancy Lynch, a retired school social worker from Des Moines, said she worked with parents of children with disabilities who were denied services and assistance. Lynch said she believes work requirements “will add more barriers to people who need these services, they will lose the support they need.”

“My job was to help support parents who had children with very special needs that needed help — needed help with health care, needed help with services — and I saw how difficult it was for them to receive those services,” she said. “No one got it on the first time. Everybody had to apply three and four times. They’d say the same thing, but they had to reapply and reapply and reapply. So they had to kind of beat down the system until they were finally accepted.”

Speakers also raised concerns about how HHS would assess mental illnesses and provide exemptions.

Many also expressed frustration that the HHS staff who hosted the meeting did not respond to questions about certain details of the policy or how it would be implemented, or if there would be changes made to address any of their concerns. HHS staff at the meeting said the comments and questions would be shared with state leaders, and would be used to answer questions about work requirements in future communications.

Report: Two-thirds of Iowans on Medicaid are already working

According to the nonprofit health care advocacy and reporting organization KFF, two-thirds of adults on Iowa Medicaid are already working. Among those not working are disabled and sick Iowans, caregivers, and full-time students. About 8 percent of Medicaid adults reported that they are retired, unable to find work, or were not working for another reason.

Additionally, many Medicaid adults who work are employed by small businesses with historically low employer-sponsored health insurance rates. Even if eligible for job-based insurance, some low-wage workers may not take up the offer because it is not affordable, according to a KFF analysis of 2024 U.S. census data.

Religious and medical groups, community providers and disability rights advocates, however, say past evidence in other states shows work requirements impose administrative barriers and red tape that lead to coverage losses among both people who are working as well as people who have caretaking responsibilities, disabilities or illnesses that keep them from paid work.

The nonpartisan Congressional Budget Office in 2023 estimated national work requirements would lead to $109 billion in federal saving over a 10-year period, but in doing so would increase the number of people without health insurance by 600,000 but would not increase employment.

U.S. House Republicans have proposed work requirements as part of a broader legislative package of potential changes to Medicaid as part of a budget framework that calls for steep spending cuts to help offset the cost of extending expiring tax cuts.

‘There are a lot of problems I have with this’

Mary Nelle Trefz, advocacy network director of Iowa ACES 360, called for the state to share information about the cost of implementing work requirements, pointing to the need for HHS to create a new information technology system and train staff to implement and support the reporting requirements.

Trefz said veterans receiving SNAP food benefits would be exempt from Medicaid work requirements, but a veteran on Medicaid alone would still need to comply.

Lori Hunt, 53, of Des Moines, said while the proposed waiver provides an exemption to those receiving unemployment benefits, the state in 2022 shortened the number of weeks that Iowans can receive unemployment benefits from 26 weeks to 16.

“And I just ended my 16th week on unemployment,” Hunt said. “I applied for everything, you know, and really, honestly, with my education … (and) work background, I mean, I've had a hard time finding a job in this environment.”

Hunt said “there are a lot of problems I have with this.”

“The first of all is the majority of people that are on Medicaid are children and elderly,” she said. “So to go after the work requirement goes after a really narrow segment of people that are doing this.”

How to comment on the proposed Medicaid work requirements

The Iowa Department of Health and Human Services will host another public hearing to gather input on the proposal to require most able-bodied Iowa Medicaid patients to work at least 100 hours per month to receive coverage.

The hearing will be held April 29 at 2 p.m. at the Marshalltown Public Library, 105 W. Boone St., Marshalltown.

Comments also can be submitted through email and by mail through May 15, with information available on the Iowa HHS website, hhs.iowa.gov.

For questions about who qualifies for the Iowa Health and Wellness Plan, call Member Services toll free at 1-800-338-8366 or email IMEmember@hhs.iowa.gov.

What is the state requesting?

Iowa HHS is requesting approval from CMS to amend the state's Iowa Health and Wellness Plan (IHAWP). The amendment would require certain IHAWP members to meet work requirements to keep their health coverage.

IHAWP provides health care to low-income, uninsured Iowans aged 19 to 64. The state aims to implement these requirements for non-exempt members to promote economic stability and reduce reliance on public assistance.

What are the proposed requirements?

Individuals must meet one of the following requirements for qualifying activities to keep their coverage:

Who is exempt?

Work requirements apply only to IHAWP members ages 19—64, unless exempt.

Exemptions include:

When would the requirements go into effect?

HHS is requesting CMS approval, effective July 1, 2025.

Implementation is planned for 2025, with a target start date of Jan. 1, 2026.

How will the state check eligibility compliance?

HHS will check information available for Iowa Medicaid members, and will create a mobile application for members to submit required information when HHS does not have information to confirm compliance.

If HHS does not have required information and a member does not submit required information, health coverage will be suspended. Members will be disenrolled from the Iowa Health and Wellness Plan at their annual renewal date if verification information is not submitted or if the member does not meet requirements for the following six months.

Comments: (319) 398-8499; tom.barton@thegazette.com