PCPs grant Medicaid work exemptions based on administrative burden and political ideology

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October 13, 2021

2 minutes to read

Source / Disclosures

Disclosures: Schmidt claims to have received grants from the Research in Transforming Health and Health Care Systems program of the Robert Wood Johnson Foundation. Please see the study for relevant financial information from all authors.


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Researchers have found considerable variation in doctors’ willingness to help patients who are exempt from Medicaid work, according to the results of a survey published in JAMA Health Forum.

Despite research showing that most beneficiaries already meet work requirements or would qualify for exemptions, “on average, one in two physicians would not help a patient, even when the patient qualifies for an exemption”, Harald Schmidt, MA, PhD, an assistant professor of medical ethics and health policy at the University of Pennsylvania, told Healio Primary Care. “This is really very bad news from a patient perspective, and we didn’t expect to find this.”

Schmidt H, et al. JAMA Health Forum. 2021; doi: 10.1001 / jamahealthforum.2021.2932.

Schmidt and colleagues conducted a mail survey experiment to assess the willingness of physicians to help patients seeking exemption from the Medicaid work requirement, which requires 80 to 100 hours of activity to be completed. qualifying per month, such as job search or caregiving, in order to maintain insurance coverage. Researchers interviewed primary care physicians in Arkansas, Kentucky, Indiana, and New Hampshire in July and October 2019. Work requirements were approved in these four states, although all four did not. implemented the policy. Currently, the waiver status has been struck down by courts in Arkansas, Kentucky and New Hampshire, while Indiana has approved and implemented the waiver, according to the Kaiser Family Foundation.

Variability in the granting of exemptions

The study included responses from 715 PCPs. Their average age was 54 and 61% were men. Ideologically, 25% of respondents identified as Democrats, 22% as Republicans, 28% as independents / others, and 26% were unknown.

Harald schmidt

On average, 29% of physician charts included Medicaid patients. When treating Medicaid patients, 25% of those polled said they would contribute to work exemptions, even when their state’s policy did not support it, according to Schmidt and colleagues. However, 54% of those polled said they would not help, even when their state’s policy required it. Additionally, 20% of respondents said they would not help when they felt an exemption was appropriate.

Compared to Democrats, doctors who identified as Republicans had a 74.5% reduced likelihood (95% CI, 42.7-88.7) of helping with an exemption. Meanwhile, physicians who identified as independent / other had a 61.2% reduced likelihood (95% CI, 18.2-81.6) of helping, according to the researchers.

The job requirement was approved by 58.6% of those surveyed, with particularly high approval in Indiana and low approval in New Hampshire. Overall, 54.1% of respondents felt poorly informed about their role in the exemption process. In addition, 54.2% considered that the administrative effort required to grant an exemption was inappropriate.

Ethical considerations

Deciding on exemptions based on cumbersome exemption procedures and personal or political opinions raises medical, ethical and legal questions, the researchers wrote.

“Patients who meet the criteria for medical frailty shouldn’t have to check their doctors’ voter registration records to make sure they’re exempt and don’t lose coverage,” Schmidt said.

In addition to the “cumbersome” process of granting an exemption, the researchers found variations in the documents required.

“If states are sincere in making it easy for physicians to help vulnerable patients with exemptions, there is certainly a lot of room for improvement,” Schmidt said.

He added that, on the whole, these findings will remain relevant “until there is broad consensus and legal assertion that the demands of the job conflict with Medicaid’s fundamental goal of provide access to health care “.

The references:

Medicaid Waivers Tracking: State approved and pending Section 1115 waivers. https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/#Table2. Posted October 8, 2021. Accessed October 11, 2021.

Schmidt H, et al. JAMA Health Forum. 2021; doi: 10.1001 / jamahealthforum.2021.2932.


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