Penn Bioethics Seminar Series: Harald Schmidt, MA, PhD, Julia Szymczak, PhD, Andrew Spieker, PhD, David Grande, MD, MPA

Implementation of Medicaid work requirements: Physicians’ willingness to request exemptions for vulnerable populations
 

In 2018, CMS approved applications from Kentucky (KY), Indiana (IN) Arkansas (AR) and New Hampshire (NH) to implement community engagement, or work requirements (WRs) as a condition of Medicaid eligibility undr Sec. 1115 Waivers. In addition to these initial 4 states, applications from 5 further states' were approved later, and 9 are pending. WRs have many elements. A central one is to require completion of between 80-100 hours per month of work, training or other activities to maintain access to Medicaid coverage.  Proponents claim that WRs are a promising tool to promote a broader notion of health and independence. Opponents view them as callous means to differentiate between deserving and undeserving poor, and a thinly veiled measure aiming to cut cost by reducing Medicaid enrollee numbers through red tape.  Primary care physicians (PCPs) play a key role in implementing WR policies. First, PCPs can assist with exemptions from WRs via disability or ‘medically frail status’. Second, PCPs may face non-exempt patients who failed to meet WRs and consequently have suspended coverage, but still seek services. Position statements and prior research suggest that PCPs may be opposed to WRs and may seek to protect patients from possible harm. However, it is unknown how physicians will react to new work requirements with respect to seeking exemptions or facilitating continuity of care.  This works-in-progress presentation reports emerging findings from a mailed survey fielded to PCPs in KY, IN, AR and NH. The survey elicited PCPs’ attitudes towards WRs and the factors that shape their responses towards patients facing WRs. At the core of the survey is an experiment, in which PCPs are presented with a vignette of a 50 year old patient who reports being depressed and asks for help with an exemption from WRs.

WRs have been controversial from the outset and the US supreme court is likely to consider their legality in 2020. While our study elicited attitudes and responses to a hypothetical scenario only, the findings are important as they indicate that patient welfare is not only dependent on rigid program features of WR policies, but also on softer factors, such as PCPs’ attitudes. Further, while the opportunity to request exemptions matters ethically in terms of reducing possible harms from WRs, in practice, PCPs may simply find the administrative effort (which we captured separately) overly burdensome, and fail to assist on these grounds, requiring a review of the steps required to enable exemptions. Finally, the study also adds to the literature of physicians engaging in ‘workarounds’ in cases where their personal views do not align with steers that are either explicit and implicit in policies.

Harald Schmidt, MA, PhD  |  Assistant Professor, Medical Ethics & Health Policy, UPenn
Julia Szymczak, PhD  |  Assistant Professor, Department of Biostatistics, Epidemiology and Informatics, UPenn
Andrew Spieker, PhD  |  Assistant Professor of Biostatistics, Vanderbilt University
David Grande, MD, MPA  |  Associate Professor of Medicine, UPenn