Joan Alker is the Executive Director of the Center for Children and Families and a Research Professor at the Georgetown McCourt School of Public Policy
Oklahoma has one of the highest uninsured rates for children in the nation, and the state will likely make matters worse if it gets a green light from CMS to go through with a plan to impose more red tape requirements on poor parents.
Oklahoma is seeking approval to amend its Section 1115 demonstration waiver to impose a work or community service requirement on Medicaid beneficiaries with incomes at or below 45% of the federal poverty level. These are families whose income is no more than $779 a month for a family of three. Parents of children under 6 years old would be exempt but it is unclear how a parent would claim such an exemption. The state itself projects that the vast majority of parents who would be impacted by this new proposal are very low income – below 20% of the poverty line, just $346 a month for a family of three.
Who are these families? Our analysis, released today with the Oklahoma Policy Institute, found that more than three quarters (78%) are mothers and 39% of these parents are under age 30. They are most likely to be white (64%) but African Americans are disproportionately represented (19%). These families are more likely to live in rural areas and small towns. The vast majority (85%) of these parents have been in the workforce or have a family member that has been in the workforce over the past six months.
Supporting very poor mothers and helping them find work is a good objective but this proposal will not achieve that goal. There are no new resources identified to help these parents overcome barriers to employment such as childcare, job training or transportation. The counties where adults are enrolled in Medicaid at the highest rates are also those counties with the highest unemployment numbers – especially rural counties. These areas are likely to be the hardest hit by this proposal relatively speaking – nine out of ten counties with the highest unemployment rates being rural ones where finding a job is the most difficult.
The practical effect of Oklahoma’s proposal will be to take away Medicaid coverage from very poor parents either because they get tripped up in a bureaucratic maze and don’t get an exemption they are supposed to or because they fail to comply with the new work requirement, which may be due to the fact the they are simply unaware of the new reporting requirement. This is not idle speculation but reinforced by the first round of data released by Arkansas last month – the first state to implement a work requirement. In Arkansas Medicaid beneficiaries can only submit their information online through a complex account system they must interact with in order to maintain their Medicaid coverage. In the first month, almost ¾ of those required to do so did not take action online. These large numbers suggest that beneficiaries are unaware of or unable to comply with the new system.
Many of these parents who would lose Medicaid coverage are likely to become uninsured because the prevalence of employer sponsored insurance in Oklahoma for low wage workers is very low – only 11% of low-wage workers with earned income below the poverty line have Employer Sponsored Insurance. Now back to my first point on how Oklahoma’s waiver proposal would be harmful to children. Children would be put at risk in the following ways:
- As their parents become uninsured the entire family is at greater risk for medical debt and even bankruptcy – moving these families in the opposite direction of economic self-sufficiency. Families at this income level already experience very high levels of homelessness and residential instability as well as higher rates of health problems. A host of studies find that having Medicaid improves families’ economic prospects.
- A healthier parent is a better parent. For example, Medicaid coverage has been shown to clearly reduce the incidence of maternal depression by increasing access to mental health screening and services. Maternal depression is epidemic among very low-income women and inhibits parent-child bonding in the critical early years of development. When parents lose health coverage, they lose access to the care they need to maintain their own health so they can support their children’s healthy development.
- As parents become uninsured, research is clear that children are more likely to not have coverage as well. An insured parent almost never has an uninsured child, but when a parent is uninsured it increases the odds that the child too will be uninsured. This is particularly troubling in Oklahoma as it has one of the highest uninsured rates for children in the country – at 7.3% it is considerably above the national average of 4.5 percent.
 There appears to be a typographical error in Table 2 of the proposal on p. 11 – 6,193 parents with incomes below 20% of the poverty line are referenced as having exemptions, but the description of the table suggests that these are the parents without exemptions.