How Might Older Nonelderly Medicaid Adults with Disabilities Be Affected By Work Requirements in Section 1115 Waivers?

Most of the states with approved or pending Section 1115 waivers that condition Medicaid eligibility on work would apply those requirements to all or most nonelderly adults (ages 19-64) who are not receiving Supplemental Security Income (SSI) cash assistance, including older nonelderly adults (ages 50-64).¹ Older nonelderly adults may be limited in their ability to satisfy a work requirement due to barriers resulting from age and/or disability. Previous analysis shows that many nonelderly Medicaid adults (ages 19-64) have functional limitations that may interfere with their ability to work but do not rise to the stringent SSI level of disability, making them potentially subject to work requirements. Older nonelderly adults are over twice as likely to have a disability than younger adults (17% vs. 7%).² Furthermore, older nonelderly adults account for nearly half (45%) of all nonelderly Medicaid adults with a disability but not SSI who could be affected by a work requirement.³ This analysis examines the implications of work requirements for Medicaid adults ages 50 to 64 (referred to as “older nonelderly Medicaid adults”) and provides national and state level estimates of their disability, SSI, and work status using data from the 2016 American Community Survey (ACS).

How might older nonelderly #Medicaid adults ages 50 to 64 with disabilities be affected by #workrequirements in Section 1115 #waivers?

Key Findings

Of the 8.7 million older nonelderly Medicaid adults, nearly half (48%) report having a disability according to the ACS definition (Figure 1). The ACS classifies a person as having a disability if the person reports serious difficulty with hearing, vision, cognitive functioning (concentrating, remembering, or making decisions), mobility (walking or climbing stairs), self-care (dressing or bathing), or independent living (doing errands, such as visiting a doctor’s office or shopping, alone).⁴

Over half (53%) of older nonelderly Medicaid adults with a disability do not receive SSI cash assistance (Figure 1); these adults could be subject to a Medicaid work requirement, despite experiencing serious difficulty in at least one ACS functional area. Although the Centers for Medicare and Medicaid Services (CMS) work requirement guidance excludes people who are eligible for Medicaid based on a disability (such as those who receive SSI), many adults with disabilities will face Medicaid work requirements because they qualify for Medicaid on another basis (i.e., low-income).⁵ The CMS guidance allows states to apply work requirements to “working age” enrollees (those under age 65).  The guidance provides that states “may” provide exemptions from a work requirement, such as an exemption based on age, but leaves that decision up to the states. People subject to work requirements must verify that they are meeting the required number of hours or meet a specified exemption.

Eight of the 10 states with approved or pending Medicaid work requirement waivers as of March, 2018, would apply those requirements to all or most older nonelderly Medicaid adults.⁶ Just two states (Arkansas and Wisconsin) would exempt all older nonelderly (age 50+) Medicaid adults from work requirements. One state (Arizona) would exempt those age 55 and older, and two states (Indiana and Utah) would exempt those age 60 and older. Medicaid work requirements would apply to all older nonelderly Medicaid adults in the remaining five states (Kansas, Kentucky, Maine, Mississippi, and New Hampshire) under the current proposals (Table 1).

Table 1:  State Section 1115 Medicaid Work Requirement Waivers, as of March 13, 2018
State	Waiver Status	Covered Populations*	Age Group Exemption
Arkansas	Approved – implementation June, 2018	Expansion adults	50+
Arizona	Pending	Expansion adults	55+
Indiana	Approved – implementation 2019	Expansion and traditional adults	60+
Kansas	Pending	Traditional adults (parents 0-38% FPL)	65+
Kentucky	Approved – implementation July, 2018	Expansion and traditional adults	65+
Maine	Pending	Traditional adults (parents 0-105% FPL)	65+
Mississippi	Pending	Traditional adults (parents 0-27% FPL)	65+
New Hampshire	Pending	Expansion adults	65+
Utah	Pending	Traditional adults (parents 0-60% FPL; childless adults 0-100% FPL)	60+
Wisconsin	Pending	Traditional adults (childless adults 0-100% FPL)	50+
NOTE:  *Other groups, such as Transitional Medical Assistance, family planning only, or former foster care youth, may be included in some states. SOURCE:  Kaiser Family Foundation analysis of states’ Section 1115 waiver applications posted on Medicaid.gov.

In the eight states that would apply Medicaid work requirements to all or most older nonelderly adults, substantial shares of these adults have a disability but do not receive SSI, making them subject to the work requirement unless they are otherwise exempt.⁷ The share of older nonelderly Medicaid adults with a disability but not SSI in these states ranges from 39% in Utah⁸ to 64% in Arizona.⁹  These shares are 63% in Indiana¹⁰ and 53% in Kentucky, the two states with CMS approval to implement work requirement waivers that include all or most older nonelderly Medicaid adults to date (Figure 2).  (Arkansas also has CMS approval to implement a Medicaid work requirement, but, as indicated above, its waiver exempts adults ages 50 and over.)

Just over 1 in 10 (13%) older nonelderly Medicaid adults with disabilities but not SSI are working 20 or more hours per week (Figure 3). The majority (83%) of older nonelderly Medicaid adults with a disability but not SSI are not working (unemployed or not in the labor force) (Table 3). For comparison, Kentucky’s approved waiver requires enrollees under age 65 to work 80 hours per month (equivalent to 20 hours per week), and Indiana’s approved waiver scales up to a requirement of 20 hours per week (after 18 months of enrollment) for those under age 60. Work rates vary, but are generally low, in the eight states with approved or pending Medicaid work requirement waivers that do not exempt any older nonelderly Medicaid adults based on age. In these states, the share of older nonelderly Medicaid adults with a disability but not SSI who are working 20 or more hours per week ranges from 10% in Mississippi to 16% in Kansas. (Figure 3).

Discussion

Most of the states with approved or pending Medicaid work requirement waivers would apply those requirements to all or most older nonelderly adults. Older nonelderly adults may face age-related barriers to complying with work requirements, and these barriers may be compounded for those who also have a disability. For example, people with low incomes are likely to be working in jobs with physical demands, such as being on one’s feet all day, walking, carrying or lifting heavy items, or performing repetitive motions. These jobs can be increasingly difficult to perform as people age. In addition, over half of older nonelderly Medicaid adults have a disability but do not receive SSI cash assistance. This population could be subject to work requirements despite experiencing a disability that limits their ability to work, such as a serious difficulty in the ability to hear; see; concentrate, remember, or make decisions; walk or climb stairs; or perform daily self-care and/or independent living tasks.

In Indiana and Kentucky, the two states with approved work requirement waivers that apply to all or most older nonelderly Medicaid adults, substantial shares of this population (63% in IN,¹¹ and 53% in KY) have a disability but do not receive SSI. They therefore could be adversely affected if they do not comply with the work and documentation requirements or obtain an exemption, which depends on what the state exemption policies are and how they are implemented. By contrast, small shares of older nonelderly Medicaid adults with a disability but not SSI in these states are currently working at a level likely to satisfy the work requirement (20 or more hours per week, 13% in IN,¹² and 15% in KY). Some older nonelderly adults with disabilities but not SSI might be exempt from the work requirement if they are determined to be “medically frail.” However, it is unclear whether everyone in this group will qualify for an exemption, how the process will work, and what specific criteria will apply.

Kentucky plans to implement its work requirement in July, 2018, and Indiana plans to implement in 2019. As these waivers are implemented, it will be important to monitor the impact on Medicaid beneficiaries, especially those whose older age and/or health status could affect their ability to comply. It will be important to assess how the work requirements and exemptions affect older nonelderly Medicaid adults with disabilities and the impact on access to coverage and care.

Table 2: Older Nonelderly Medicaid Adults by Disability and SSI Status, 2016
	Total Older Nonelderly Medicaid Adults Ages 50-64	Total Older Nonelderly Medicaid Adults with a Disability	Older Nonelderly Medicaid Adults with a Disability but Not SSI
			As a Share of Older Nonelderly Medicaid Adults with a Disability	Number
US Total	8,730,300	4,161,500	53%	2,222,700
Alabama	117,300	75,100	43%	32,400
Alaska	14,600	6,700	54%	3,600
Arizona	214,200	97,600	64%	62,100
Arkansas	103,300	53,100	53%	28,300
California	1,455,700	506,400	57%	286,400
Colorado	134,200	59,000	61%	36,100
Connecticut	108,300	41,300	66%	27,100
Delaware	27,700	12,400	52%	6,400
DC	33,400	14,900	66%	9,800
Florida	465,700	251,400	48%	120,400
Georgia	192,900	121,000	39%	47,300
Hawaii	34,800	11,200	57%	6,500
Idaho	22,100	13,500	40%	5,500
Illinois	344,600	156,100	64%	99,600
Indiana	153,000	83,900	63%	53,100
Iowa	75,100	36,500	56%	20,400
Kansas	41,000	26,700	51%	13,600
Kentucky	192,900	104,400	53%	55,500
Louisiana	143,700	84,100	47%	39,200
Maine	41,600	25,500	46%	11,800
Maryland	148,000	71,900	56%	40,200
Massachusetts	275,700	105,800	56%	59,000
Michigan	344,200	180,400	54%	97,300
Minnesota	135,200	56,300	64%	36,300
Mississippi	83,900	53,300	49%	26,000
Missouri	110,400	70,200	59%	41,600
Montana	28,000	15,500	60%	9,300
Nebraska	20,700	13,000	49%	6,400
Nevada	76,700	34,700	59%	20,300
New Hampshire	25,900	11,500	57%	6,500
New Jersey	216,500	87,500	46%	40,000
New Mexico	85,400	40,500	56%	22,600
New York	811,100	290,400	53%	154,100
North Carolina	199,800	116,300	50%	57,800
North Dakota	10,300	5,700	51%	2,900
Ohio	331,200	162,100	64%	103,100
Oklahoma	61,000	41,300	50%	20,800
Oregon	140,100	63,400	58%	36,500
Pennsylvania	360,500	199,700	52%	104,800
Rhode Island	41,100	21,700	40%	8,700
South Carolina	109,700	67,700	47%	32,100
South Dakota	11,700	7,100	39%	2,800
Tennessee	178,100	114,300	47%	53,200
Texas	411,400	246,300	43%	106,300
Utah	32,200	18,900	39%	7,300
Vermont	26,800	9,800	52%	5,100
Virginia	99,400	57,700	58%	33,700
Washington	205,200	98,700	61%	60,000
West Virginia	84,900	45,900	54%	24,600
Wisconsin	140,000	68,200	54%	36,800
Wyoming	9,100	5,100	34%	1,700
NOTES: Includes non-institutionalized nonelderly adults ages 50-64. SSI = Supplemental Security Income. Disability includes serious difficulty with hearing, vision, cognitive functioning, mobility, self-care, or independent living. SOURCE: Kaiser Family Foundation analysis based on the 2016 American Community Survey, 1-Year Estimates.

Table 3: Work Status of Older Nonelderly Medicaid Adults with a Disability but Not SSI, 2016
	Total Non-SSI Medicaid Adults with Disabilities, Ages 50-64	Total Working	Share Working	Share Working 20+ Hours/Week	Share Working <20 Hours/Week	Share Unemployed or Not in Labor Force
US Total	2,222,700	370,200	17%	13%	3%	83%
Alabama	32,400	2,500	8%	7%	N/A	92%
Alaska	3,600	N/A	N/A	N/A	N/A	85%
Arizona	62,100	10,600	17%	14%	3%	83%
Arkansas	28,300	3,200	11%	9%	N/A	89%
California	286,400	53,300	19%	16%	3%	81%
Colorado	36,100	7,100	20%	14%	5%	80%
Connecticut	27,100	4,100	15%	12%	N/A	85%
Delaware	6,400	1,600	24%	23%	N/A	76%
DC	9,800	N/A	N/A	N/A	N/A	84%
Florida	120,400	13,500	11%	9%	N/A	89%
Georgia	47,300	4,600	10%	8%	N/A	90%
Hawaii	6,500	N/A	N/A	N/A	N/A	85%
Idaho	5,500	N/A	N/A	N/A	N/A	84%
Illinois	99,600	16,200	16%	13%	3%	84%
Indiana	53,100	8,500	16%	12%	N/A	84%
Iowa	20,400	5,500	27%	19%	8%	73%
Kansas	13,600	2,400	18%	16%	N/A	82%
Kentucky	55,500	9,300	17%	15%	N/A	83%
Louisiana	39,200	4,000	10%	8%	N/A	90%
Maine	11,800	N/A	N/A	N/A	N/A	87%
Maryland	40,200	9,000	22%	19%	N/A	78%
Massachusetts	59,000	12,900	22%	16%	6%	78%
Michigan	97,300	18,300	19%	14%	5%	81%
Minnesota	36,300	11,000	30%	22%	9%	70%
Mississippi	26,000	3,000	11%	10%	N/A	89%
Missouri	41,600	4,300	10%	8%	N/A	90%
Montana	9,300	1,600	N/A	N/A	N/A	83%
Nebraska	6,400	N/A	N/A	N/A	N/A	76%
Nevada	20,300	1,900	10%	N/A	N/A	90%
New Hampshire	6,500	N/A	N/A	N/A	N/A	81%
New Jersey	40,000	7,400	18%	15%	4%	82%
New Mexico	22,600	5,800	26%	23%	N/A	74%
New York	154,100	32,800	21%	18%	3%	79%
North Carolina	57,800	5,500	10%	8%	N/A	90%
North Dakota	2,900	N/A	N/A	N/A	N/A	92%
Ohio	103,100	17,500	17%	13%	3%	83%
Oklahoma	20,800	2,100	10%	10%	N/A	90%
Oregon	36,500	7,800	21%	17%	N/A	79%
Pennsylvania	104,800	19,000	18%	12%	6%	82%
Rhode Island	8,700	2,300	26%	25%	N/A	74%
South Carolina	32,100	3,800	12%	10%	N/A	88%
South Dakota	2,800	N/A	N/A	N/A	N/A	84%
Tennessee	53,200	6,700	13%	11%	2%	87%
Texas	106,300	14,500	14%	11%	3%	86%
Utah	7,300	N/A	N/A	N/A	N/A	87%
Vermont	5,100	N/A	N/A	N/A	N/A	69%
Virginia	33,700	3,800	11%	10%	N/A	89%
Washington	60,000	11,300	19%	13%	6%	81%
West Virginia	24,600	3,700	15%	12%	N/A	85%
Wisconsin	36,800	6,200	17%	13%	4%	83%
Wyoming	1,700	N/A	N/A	N/A	N/A	75%
NOTES: Includes non-institutionalized nonelderly adults ages 50-64. SSI = Supplemental Security Income. Disability includes serious difficulty with hearing, vision, cognitive functioning, mobility, self-care, or independent living. SOURCE: Kaiser Family Foundation analysis based on the 2016 American Community Survey, 1-Year Estimates.