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  • Medicaid, Vital to Social Work Under Attack

    By Kristi Wood, MSW, APSW and James Scherrer, PhD, LCSW 

    Medicaid covers services for people who have low levels of income. Although Medicaid is best known as a program for the poor, more than 80 percent of the Medicaid budget provides services for the elderly, children, and people with disabilities; only a small percentage goes toward providing health care for able-bodied adults (Kodjak, 2017). Social work ethical standards rest on the premise that society functions best when all individuals have their basic needs met. Social workers have a duty to advocate for the well-being of all people in society, particularly those who are vulnerable. New federal guidelines will artificially reduce the numbers of people receiving Medicaid. This article reviews the impact of the changes in the new guidelines and calls for social workers to advocate with states not to seek waivers that will prevent millions of vulnerable people from receiving the health care they need.

    Children and Medicaid

    Medicaid covers 27 million children in the United States (Centers for Medicare and Medicaid Services, 2018). The Centers for Medicare and Medicaid Services (CMS) issued new guidelines for Medicaid coverage by states. These guidelines allow states to apply for waivers on providing health insurance coverage under the Affordable Care Act. Prior to these new guidelines, several states had requested and received waivers that permitted them to add some requirements to their provision of Medicaid. These waivers included work requirements (but not for parents of children), co-payments (but not to exceed 2 percent of the recipient’s income), and other smaller requirements (Stein, 2018). The new guidelines permit work requirements for parents of children under 17 but prohibit funds being used to pay for day care services. The guidelines also permit the establishment of co-payments even for those far below the poverty line. States are also permitted to terminate Medicaid coverage for those who have not paid their premium for six months  Alker, 2018).

    TheMedicaid intent of these guidelines is either to reduce the number of people qualifying for Medicaid or to prevent those who would otherwise qualify from actually enrolling (because they could not afford the premium). The effect, whether intended or not, is that children may be deprived of their right to health insurance and, by extension, health care. Typically, parents who have their own health insurance also have health insurance for their children. One of the benefits of the Affordable Care Act was its provision of health insurance to parents and their children, so that by the end of 2017, 700,000 previously uninsured children received health insurance, primarily through Medicaid (Center on Budget and Policy Priorities, 2018).

    This deprivation will have a particularly high impact on children who are three years of age or younger. Parents of children this age tend to be younger, they are new to the workforce and qualify only for entry-level jobs, and they experience a high level of work insecurity. In addition, day care is often more than they can afford, and these parents find themselves often choosing between employment or caring for their children Haley, Wang, Buettgens, & Kenney, 2017). The new guidelines seek a cost savings of about $43 billion over the next 10 years exclusively at the expense of the very poor and their children (Avalere, 2017).

    It is noted in Article 24, Section 1, of the United Nations Convention on the Rights of the Child that the child has the right “to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health.” In addition, governments “shall strive to ensure that no child is deprived of his or her right of access to such health care services” (United Nations Human Rights Council, 2018).  Although the United States has not ratified this document, it is a recognition of the rights inherent to childhood. Thus, the government has an obligation to ensure that every child—regardless of his or her race, ethnicity, religion, economic status, or any other characteristic—has direct access to health care. The new federal guidelines are a direct violation of this principle.

    While the argument can be made that the United States is not obligated by this convention, it does not relieve it from its duty to respect and honor the inherent rights of its most vulnerable citizens. These rights exist as the very nature of childhood and hence are not politically negotiable. The question then becomes not if the government will recognize and ensure that these rights are respected and the needs associated with them are met, but how it can most effectively provide for the means by which they are met.

    Medicaid and Adults: A Wisconsin Example

    Wisconsin is among 10 states seeking work requirements for Medicaid recipients. Approximately 1.2 million Wisconsin residents, or roughly 20 percent of the state’s population, are enrolled in Medicaid programs (Sommerhauser & Beck, 2017).  Nationwide, Medicaid covers more than 70 million people (Alonso – Zaldivar, 2018).

    Governor Scott Walker has asked President Trump to allow Wisconsin to impose a four-year time limit on coverage for childless adults unless they work or train for a job, and he is also looking to require drug  screening for Medicaid coverage. This request ignores a Kaiser Foundation study that found working-age adults on Medicaid are already employed: nearly 60 percent work either full or part time. Most who are not working report reasons such as illness, caring for a family member, or going to school. In addition, the National Association of Medicaid Directors has stated that there is no consensus on whether work requirements are the right approach to Medicaid reform (Alonso-Zaldivar, 2018).

    Agencies such as Our Place in Slinger, Wisconsin—which provides case management and daily living skills supporting Medicaid recipients who have cognitive disabilities—are likely to close their doors if planned Medicaid cuts are enacted (Kodiak, 2017). Wisconsin’s Medicaid system includes IRIS (Include, Respect, I Self-Direct), a Medicaid Home and Community-Based Services waiver for self-directed long-term supports and services for people with disabilities. The Congressional Budget Office predicts that the current federal budget plan will decrease Medicaid funding levels by 25 percent in 10 years. The Survival Coalition of Wisconsin Disability Organizations estimates that programs for people with disabilities will be cut by 56 percent and will zero-out the State Councils on Developmental Disabilities, Independent Living, and Traumatic Brain Injury (Wisconsin Board for People with Developmental Disabilities, 2018).

    Wisconsin began rolling out the Comprehensive Community Services (CCS) program in select counties in 2005, and it is now available in 66 out of the state’s 72 counties as well as in three tribes. In 2017, more than 5,800 individuals were served. CCS works with individuals of all ages who need ongoing services for a mental illness,  substance use disorder, or a dual diagnosis beyond occasional outpatient care but less than inpatient treatment. CCS is entirely funded  y Medicaid. Any cuts to Medicaid will directly result in reduced numbers of people served by the program, people who otherwise cannot  afford these crucial services (Department of Health Services, 2018). Furthermore, the majority of Medicaid recipients are elderly. Large numbers of seniors will be cut from Medicaid rolls because of these budget cuts (Norris, 2017). 

    Need for Social Action

    The time for  social work action is now. We as social workers have a responsibility to advocate strongly for the people we serve. We can also work with and educate legislators on the impacts these cuts will have on the most vulnerable among us. Many states hold NASW events to provide social workers an opportunity to educate their state legislators about issues that affect the people we serve. More than 500 social  workers and social work students attended NASW-WI’s biennial Advocacy Day in April 2017.

    It is not enough to work only with our legislators, however. Social workers can educate their fellow social workers about how to advocate for the people we serve, and social workers must actively educate the public, particularly voters, about the importance and necessity for governments to provide for those who do not have the resources to care for themselves. Social workers should be attending town hall meetings and participating in letter-writing campaigns and organized meetings in state capitals to make known the serious consequences of reducing Medicaid to vulnerable people.

    Finally, social workers should “get out the vote” for candidates for public office—locally, statewide, and nationally—who support providing health care to those most in need. We must understand that the most convincing argument for legislative responsibility comes from the power of the vote. This is the way we hold our legislators accountable, and we must work with the larger voting public to ensure that our legislators understand their responsibilities as servants of all the people. Medicaid is a social safety net program that is critical to the well-being of many of the children, parents, and elders we serve.  

    James Scherrer, PhD, LCSW, is an associate professor in the School of Social Work of Dominican University. He has more than 40 years of experience in providing child welfare services to poor and inner-city youth. Currently, he is engaged in research to determine if, how, and in what way the United Nations Convention on the Rights of the Child has changed the lives and futures of children throughout the world. He can be reached at  

    In service to the social workers of Wisconsin,

    Kristi Wood, MSW, APSW

    President, NASW-WI