Back in January, I argued against the general idea of imposing work requirements for Ohio’s Medicaid program. The details of Ohio’s proposed Medicaid work requirements (PDF link) are now open for public comment. As the proposed language makes clear, Ohio is set to go all in on the mythology that forcing the very small population of people on Medicaid who might be able to work, but do not currently, will make them healthier overall. Most health care experts who have looked at the question agree that though the requirements are likely to move a small fraction of Ohioans into the workforce, the real story is that the requirements will serve as a bureaucratic barrier for Ohioans in need. In other words, the real effect of Medicaid work requirements will be a reduction in enrollment, not an increase in work. As the Medicaid expert Emma Sandoe noted on Twitter, “Only 4% of 945 commenters said anything positive about Ohio’s work requirement waiver.”
But now that we know more about the specifics of the proposal, there is an even more alarming reason why the proposed language must be scrutinized and–if it is not changed–ultimately rejected: like the Michigan plan that received a great deal of media attention over recent weeks, the Ohio plan uses regional exemptions for rural (but not urban) areas that racializes the proposal’s likely effects. The problem is that the rules will exempt many non-working Medicaid recipients living in Ohio’s largely white and rural counties, where employment is considered harder to come by, but do not exempt non-working Medicaid recipients in, say, Cuyahoga County, where there is a large African American population. As Plunderbund readers undoubtedly know, in practice this will mean that people of color, who predominantly live in Ohio’s urban areas, will be disproportionately affected by the rules. Experts have speculated that the Michigan rules may not pass muster under civil rights laws. The Ohio rules would seem to open themselves up to the same scrutiny.
Even more problematically, Ohio addresses the charge of racism in the following way:
A few commenters noted that the Group VIII Work and Community Engagement requirement is racially biased and will disproportionately affect African-Americans and Latinos, specifically due to the manner in which the ABAWD [Able-Bodied Adults Without Dependents] time limit waiver, and by extension Medicaid’s alignment with that waiver, is applied on a county-wide, rather than metropolitan or municipal, basis. The commenters further noted that the ABAWD waiver exempts rural counties, which have a primarily white population, from the ABAWD time limit, while racial and ethnic minorities who reside in urban areas with similar unemployment rates will be required to participate in activities to meet the Work and Community Engagement Requirement.
And the State’s response:
In following CMS guidelines, the Waiver aligns the proposed Medicaid Work Requirement, including exemptions, with those currently existing in other programs. The federally-approved SNAP [Supplemental Nutrition Assistance Program] program in Ohio currently provides work exemptions for counties with high unemployment rates, not metropolitan areas. That same exemption will be applied in this Waiver. The intent of applying this exemption is, again, to align work programs as much as possible.
What this amounts to, in essence, is a defense of one set of discriminatory requirements by pointing to another set of discriminatory requirements. Scholars have already established that SNAP’s skewed distribution, which considers neighborhood characteristics and rural vs. urban contexts, is discriminatory.
The Ohio rules deserve the same popular and media attention as the Michigan rules. Only public push-back can ensure that racially-skewed health care policy–established under the guise of celebrating the wonders of work–is not instituted in Ohio.