New Hampshire becomes the third state—joining Kentucky and Arkansas—that a federal court in Washington, D.C., has blocked from mandating that residents work a minimum number of hours a month to qualify for the state’s expanded Medicaid program.
The ruling from the U.S. District Court for the District of Columbia is a win for patients and physicians. The AMA filed an amicus brief in the case, Philbrick v. Azar, arguing that pinning eligibility for New Hampshire’s Granite Advantage plan to work requirements would cause thousands to be disenrolled from the state’s recently expanded Medicaid program, leading to worse health outcomes for them and their families. The state argued that the requirement would incentivize people to work.
“The New Hampshire system will not meaningfully ‘encourage’ beneficiaries to ‘attain or retain financial independence.’ Thinly veiled threats, or ‘incentives,’ will not help beneficiaries enter the workforce or obtain steadier employment,” the AMA brief told the court. “Thousands of Medicaid beneficiaries cannot work as a medical matter, face serious difficulties in finding employment or work too inconsistently to meet the work requirement. Holding health care coverage hostage will only exacerbate these problems.”
The brief points to a 2019 Commonwealth Fund study that projects 15,000–23,000 of the 51,000 low-income adults subject to the New Hampshire work requirement would likely be terminated from the plan within one year.
The requirement also had the potential to force community providers and hospitals to shut down or limit services, the AMA brief says. On top of that, physicians say the state would have been stuck with bigger bills as a sicker patient population sought care later at a greater expense.
Requirements stricter than Kentucky, Arkansas
The U.S. Department of Health and Human Services (HHS) issued guidance promoting the idea of imposing work requirements on people getting coverage through the Medicaid expansion. In 2018, HHS officials approved New Hampshire’s plan to terminate most adults without disabilities who work fewer than 100 hours monthly or don’t participate in other “community engagement” activities to satisfy that requirement.
The requirement was even harsher than ones Kentucky and Arkansas tried to implement, which required 80 hours a month for a smaller age range and were struck down by the same court deciding the fate of New Hampshire’s requirement.
Four New Hampshire residents challenged the new work requirements, saying it violated the Administrative Procedure Act and the Constitution. The U.S. District Court for the District of Columbia sided with the patients. The court said waivers are permitted for programs that help promote the Medicaid Act’s objectives—with the core objective being to furnish medical assistance to people who cannot afford it—and that the New Hampshire plan didn’t meet that goal.
The court also said, as it did in the Kentucky and Arkansas cases, that the HHS Secretary didn’t adequately consider the impact the state’s requirements would have on Medicaid coverage, calling the decision to allow the work requirement “arbitrary and capricious.”
“In short, we have all seen this movie before,” the decision says. Echoing arguments in the AMA’s brief, the court said “HHS did not offer its own estimates of coverage loss or grapple with comments in the administrative record projecting that the proposal would lead a substantial number of residents to be disenrolled from Medicaid.”
Patients’ health at risk
Many of the patients who don’t work and aren’t exempt from the new requirements have difficulty walking, climbing stairs and running errands because of physical limitations—ones that would make it hard for them to work or meet the community engagement environment. Others have mental illness or intellectual challenges.
“Depriving beneficiaries of coverage can devastate their health,” the AMA brief says, including people who may die prematurely without coverage. “Indeed, one life is saved for approximately every 250–300 people who gain coverage.”
