Delivering to the deserving (white) poor

As the Trump administration moves aggressively to allow more states to impose mandatory work requirements on their Medicaid programs, several states have come under fire for crafting policies that would in practice shield many rural, white residents from the impact of the new rules.

In the GOP-controlled states of Kentucky, Michigan, and Ohio, waiver proposals would subject hundreds of thousands of Medicaid enrollees to work requirements, threatening to cut off their health insurance if they can’t meet an hours-per-week threshold.

Those waivers include exemptions for the counties with the highest unemployment, which tend to be majority-white, GOP-leaning, and rural. But many low-income people of color who live in high-unemployment urban centers would not qualify, because the wealthier suburbs surrounding those cities pull the overall county unemployment rate below the threshold.

“This is sort of a version of racial redlining where they’re identifying communities where the work requirements will be in full effect and others where they will be left out,” George Washington University health law professor Sara Rosenbaum told TPM. “When that starts to result in racially identifiable areas, that’s where the concern increases.”

Rosenbaum and other health law experts say the waivers — already approved for Kentucky, pending for Ohio, and advancing in Michigan’s legislature — may run afoul of Title 6 of Civil Rights Act of 1964, which prohibits race-based discrimination in federal assistance programs. Under that statute, even policies that are racially neutral on their face but have a disparate impact on a particular group could be illegal.

The waiver in Kentucky, the first state to win federal approval for a Medicaid work requirement, will have the effect of exempting eight southeastern counties where the percentage of white residents is over 90 percent. The work requirements will be imposed first in Northern Kentucky, which includes Jefferson, the county with the highest concentration of black residents in the state. The rules are set be enforced first in that area this July, but a federal court challenge in June could decide the fate of the program.

Michigan Republicans' plan to require some recipients of government health insurance to work would disproportionately affect black people, a Washington Post analysis of new data from state health officials reveals.

State Republicans are moving a proposal through the legislature that would impose work requirements on some Medicaid recipients, arguing new rules are necessary to push people into jobs and off taxpayer-subsidized health plans.

The proposal would exempt people living in counties where the unemployment rate tops 8.5 percent, a provision GOP lawmakers say is aimed at protecting those living in areas where job opportunities are scarce.

Medicaid enrollment data provided to The Washington Post by the Michigan Department of Health and Human Services shows that this exemption would overwhelmingly benefit white people while leaving the work requirements in place for all but a sliver of the affected African American population.

Without the exemption, the work requirements are projected to apply primarily to approximately 700,000 Michigan residents enrolled in Medicaid under broader eligibility rules passed under Gov. Rick Snyder (R).

African Americans make up about 23 percent of that population, but they would make up only 1.2 percent of the people eligible for the unemployment exemption. White people make up 57 percent of the total potential affected population, but they make up 85 percent of the group eligible for the unemployment exemption, according to an analysis of the state's data.

Michigan's health department provided The Post with Medicaid enrollment data by racial and ethnic group for every county in the state. This analysis was based on the population enrolled via the state's Medicaid expansion, which health experts say is the group expected to be subject to the work requirements, because enrollees on “traditional” Medicaid are likely to be exempted. While it's possible, some experts say, that a small portion of the traditional Medicaid population would be affected by the work requirements, including that population in the analysis would not change the racial composition of the exempt group by more than about one percentage point.

Ohio’s Medicaid work requirement proposal — recently submitted for federal approval — is of a similar design, and would have the same disparities between urban residents of color in Cleveland and Columbus and rural white residents in the rest of the state.

John Corlett, Ohio’s former Medicaid director and the president of Cleveland’s Center for Community Solutions, studied the 26 counties that qualify for an exemption from the proposed Medicaid work requirements and found they are, on average, 94 percent white. Meanwhile, his research found, “most of these non-exempted Ohio communities have either majority or significant African-American populations.”

“The communities most at risk under this scenario are African American, and those communities already have significantly higher rates of infant mortality, lower life expectancy, and a number of other serious health disparities,” he told TPM.