Live Free or Die—Literally

Charles Krupa/AP Photo

An in-home nurse prepares an enteral nutrition feeding pump for a patient in Brentwood, New Hampshire.

Republicans in New Hampshire want to implement Medicaid work requirements—but like similar initiatives in a handful of other states, their plan is facing some serious roadblocks.

New Hampshire’s program began June 1, but as of yet, only 8,021 of approximately 25,000 Medicaid recipients who would be subject to the requirement—the Medicaid expansion population—have either reported work hours or logged a health or other exemption.

As those June numbers were finalized Monday, Republican Governor Chris Sununu quickly reversed positions, signing a Democrat-sponsored bill to delay implementation of the work requirement until the end of September, as it seemed inevitable that a majority of those subject to the work requirement would be in danger of losing their health coverage entirely. The bill will also expand exemptions to those experiencing homelessness and full-time students, reduce the monthly work hours requirement from 100 to 80, and end the program if more than 500 people lose coverage. “Making sure we get this right is absolutely paramount, so the idea of giving ourselves another 120 days to move forward on this and get the implementation where we need it to be, it’s not just fair to the system, but it’s fair to individuals,” Sununu said in a press conference.

New Hampshire’s struggles with Trump-approved work requirements for Medicaid join a handful of other states that have run into coverage losses and legal problems. Until Arkansas’s work requirement was blocked by U.S. District Judge James Boasberg, more than 18,000 low-income people lost Medicaid coverage after not reporting work hours. Judge Boasberg blocked Kentucky’s work requirement program before it began (the state itself had estimated nearly 100,000 people would lose coverage). Boasberg is also currently reviewing a lawsuit related to the New Hampshire work requirement.

The bill that Sununu signed this week passed the New Hampshire state legislature in June without a single Republican vote, and a veto seemed likely. Democrats pointed to Arkansas’s experience of thousands being cut from Medicaid as part of the reason for the legislation, which they passed in the Senate the same week that Judge Boasberg struck down the Medicaid work requirement programs in Kentucky and Arkansas.After the New Hampshire House then passed the bill, state House Republican Leader Dick Hinch said in a statement, “This bill significantly weakens the work requirement that has only just been implemented. I’m disappointed that Democrats broke a promise in an attempt to solve a problem that we’re not even sure exists.”

But one month later, it seems a problem exists.

Sununu signed the bill amid an outreach push from the New Hampshire Department of Health and Human Services (DHHS), as the department attempted to contact Medicaid recipients to inform them of the requirement and the need to report work hours. Besides sending thousands of letters, making thousands of phone calls, and setting up shop at grocery stores, officials are even going door-to-door in low-income neighborhoods (that is, “high-enrollment neighborhoods”) to spread word of the new requirement.

But these efforts can only go so far. “I don’t think we can outreach our way out of this situation,” Dawn McKinney, policy director for New Hampshire Legal Assistance, told the Associated Press. Outreach efforts are unlikely to reach the most vulnerable, like people who are homeless or without permanent addresses, people who don’t have access to computers or phones, or people who have severe mental illnesses. DHHS officials roaming the neighborhood for surprise visits might not be welcome, either, given the sordid history of surprise visits from officials in days of welfare past.

In March, the National Health Law Program, New Hampshire Legal Assistance, and the National Center for Law and Economic Justice filed suit against the Trump administration for its approval of New Hampshire’s work requirement plan, accusing the administration of “bypassing the legislative process” in an “unauthorized [attempt] to re-write the Medicaid Act.”

“Our position is that it’s basically the same thing. [New Hampshire’s] approval suffers from the same flaws,” inherent in the approvals for Arkansas and Kentucky, Sarah Somers told me, managing attorney at the National Health Law Program. For example, New Hampshire’s didn’t take into account that the state Medicaid program would sustain heavy coverage losses.

Somers noted that Sununu spoke of the work requirement in a “gentler” fashion than other Republican governors who saw the coverage losses as nothing more than collateral damage.

But, she says, “We don’t care how gentle [the language] is. People will lose [coverage.]” As I’ve reported previously, low-income people have difficulty meeting work requirements for a multitude of reasons, most primarily the nature of the low-wage labor market, in which work is unstable and hours may fluctuate, as well as lack of access to transportation, child care, or undiagnosed disabilities.

As Judge Boasberg blocked work requirement programs in Arkansas in Kentucky, the same outcome is expected in his ruling for New Hampshire. Senate Majority Leader Dan Feltes said in a statement that because of this litigation, Sununu’s signature on the bill was “simply a political maneuver to save face” and that “another 120 days will not make a difference.”

Unlike other Medicaid work requirement programs, New Hampshire’s is unique in that it came out of a purple state—as a compromise between Democrats and Republicans as a way to pass Medicaid expansion.

While it’s always been clear that Medicaid work requirements wouldn’t work—just take a look at work requirements in other programs for evidence—it seems that the reality of kicking thousands of low-income people off of their health care has finally set in.

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