Smart Investments for a Healthy Workforce How Benefits Support Low - - PowerPoint PPT Presentation

Smart Investments for a Healthy Workforce

How Benefits Support Low Income Kentuckians

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About work...

❏ Work is a good thing. Everyone here supports it for those who are able. ❏ Programs that provide employment-related services independent of eligibility are a good thing. They can be a way to upgrade skills, training, and education that can lead to higher wages. ❏ There are assumptions about high benefit levels, large household sizes, and length of stay on benefits to discuss. ❏ Order of discussion: older work programs to the newest

❏ Cash assistance program in Kentucky funded by the federal Temporary Assistance for Needy Families (TANF) block grant ❏ Average payment is just under $97/mo per person with an average of 2.2 persons per household. ❏ Average length of receipt for KTAP adults is around 22 months. Less than 1%

• f adults make it to the 60 month limit.

❏ Serves just under 5,000 adults and 27,000 children in about 14,000 cases; about 9,000 cases for children being cared for by relatives or disabled parents ❏ Serves less than 1% of the population of KY, and only about 20% of eligible mothers are receiving it.

Kentucky Transitional Assistance Program (K-TAP)

K-TAP’s Kentucky Works Program

❏ A fairly strict work requirement built in by federal law; and state funding depends on maintaining participation rates in specified activities. BUT… ❏ Includes a thorough assessment, case management, ongoing monitoring, and referral assistance. ❏ Participation can include a broad array of components, from employment to education to mental health counseling, or any combination of those. ❏ Provides a broad array of support services, including child care, transportation assistance of up to $200/month, vehicle repair up to $1,500, and more. ❏ Focus on education and training; supported through programs like the Ready to Work partnership with KCTCS.

SNAP (Food Assistance)

❏ Statewide SNAP Enrollment in June 2019: 527,256 ❏ Direct economic benefit in 2018: $854 million, 100% federal funds ❏ Average benefit per person in 2018 was about $1.30 per person per meal, or about $116 per person per month ❏ Average length of stay on SNAP is around 12 months. Those with recent work history stay shorter, with longer stays for low-income seniors and individuals with a disability

SNAP (FOOD ASSISTANCE)

❏ From 2013 to 2016 (recession recovery), the caseload dropped 25% with no work program in place. When people are able to go back to work, they do. ❏ About 70% of Kentucky families receiving SNAP have at least

• ne wage earner in the home with earnings in the past 12
• months. (USDA)

❏ SNAP is a vital work support. For every extra $1 in income, benefits decline about 24-36 cents, decreasing gradually and avoiding the benefits cliff of some programs (CBPP)

SNAP Participation & Work Status

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Study over a 44 month period (2009 - 2013) showed non-elderly, non- disabled SNAP participants moved in and out of work for a number of

• reasons. In the end, only a handful
• f individuals received benefits and

did not work for the full time period.

https://www.cbpp.org/blog/most-snap-participants-move-in- and-out-of-work-an-animated-look

SNAP Work Reporting Requirements

❏ January - May 2018: KY voluntarily reinstated a 3-month time limit for ”able-bodied” adults ❏ Work reporting is required in all 120 counties ❏ Jan 2018 - Mar 2019: 21,419 lost SNAP, representing $30M/yr in lost benefits

SNAP Work Reporting Requirement

Reasons for disenrollment:

❏ Lack of access to the technology required to meet work reporting requirements

“For some [using Citizen Connect] is nearly impossible because they lack access to basic technology. Many recipients don’t own the necessary tools to engage online in the way that it requires—especially when it comes to uploading documents [the primary way beneficiaries are required to verify compliance].

❏ Confusing online tools and communication of requirements

“We used to [send] a conciliation letter [a warning letter prior to disqualification]”, but now, “…most clients don’t know that they have three [noncompliant] months, until their benefits are discontinued.” (DCBS Employee) “…trying to tell them to sign in to Citizen Connect by yourself and upload your documents by yourself can kinda be overwhelming.” (quote from a SNAP partner agency)

SNAP Work Reporting Requirement

Reasons for disenrollment (cont’d):

❏ Lack of important supports like transportation

“…Getting access to a public library requires time and transportation which can be in short supply.”

❏ Lack of training

“The instructors never made it through the entire [training materials] …I feel like I am punching a button because I am told to punch a button.” (DCBS Employee)

❏ Input-driven rather than output-driven

“The current process incentivizes completing tasks and moving recipients through. It does not consider follow-up or outcomes and creates an inconsistent experience for recipients.”

Kentucky Medicaid

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Traditional Medicaid: Low-income children, pregnant women, disabled adults (1915c) and seniors ■ Covers 516,622 Kentucky children ■ Covers 376,208 Kentucky adults Expanded Medicaid: All other Kentuckians up to 138% FPL ($17,236 for an individual) ■ Covers 445,925 Kentuckians

Kentucky Medicaid: Who is covered?

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Medicaid covers most Kentuckians at some point in their life:

❏ Covers tens of thousands of Kentuckians working in jobs that don’t pay much ❏ Covers 46% of births ❏ Covers 70% of nursing home residents ❏ Covers tens of thousands of intellectually and developmentally disabled Kentuckians

Kentucky Medicaid: Good for Our Health

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More Kentuckians are covered – the

expansion of Medicaid led to a ⅔ drop in the uninsured in Kentucky.

More Kentuckians are using care – more

primary care, routine care for chronic conditions, getting drug treatment and getting screenings for cancer, hepatitis, and diabetes.

More Kentuckians are getting healthy –

fewer preventable hospitalizations, lower rates

• f breast cancer death and infant mortality and

a higher percentage reporting excellent health.

Kentucky Medicaid: Good for Our Economy

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■ Medicaid helps generate new, good paying jobs ■ Hospital finances improved after Medicaid expansion ■ Local economies got an economic boost through more health care spending

Kentucky HEALTH (1115 Medicaid Waiver)

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❏ The requirement to report acceptable levels of work, training or volunteering applies to both traditional and expansion populations. ❏ Exemptions for health reasons, caretaking responsibilities, students, and those working over 30 hours a week. ❏ Blocked twice in federal court (June 2018 and March 2019)

• Expedited appeal granted to CMS/KY – will be heard October 11
• Likely appeal to the Supreme Court regardless of outcome of appeal

❏ Even if the state were to prevail, the waiver is a demonstration that should not be placed into state statute until we see an evaluation

• f the demonstration’s impact.

Behavioral Science Behind Requirements

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Viewed through a behavioral science lens, work requirements are misguided for three key reasons:

• 1. They dramatically increase the cognitive costs of participating in a

program by imposing burdensome compliance demands

• 2. They remove “slack” from the already complex lives of people living

with low incomes

• 3. They promote harmful narratives among program staff and

administrators that disempower participants.

http://www.ideas42.org/wp-content/uploads/2019/04/ideas42-Work-Requirements-Paper.pdf

Medicaid Participation & Work Status

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A study commissioned by Ohio Governor Kasich to understand the impact of Medicaid Expansion found that simply having Medicaid coverage is a work support. In 2018, nearly 9 in 10 beneficiaries interviewed reported that Medicaid made it easier to continue working, while 60% of unemployed enrollees said Medicaid made it easier to look for work.

Medicaid Participation & Work Status

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What Does the Evidence Tell Us?

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Arkansas Work Requirements

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(Sommers, NEJM 2019)

Harvard Study ~100K Arkansans subject to new requirement 97% found to be working or exempt 3-4% not in compliance 18K lost coverage

Kentucky Work Requirements

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■ UPenn evaluators for Kentucky HEALTH found that most beneficiaries of Medicaid

in who were included in the “Community Engagement” requirement likely already meet required hours or qualify for an exemption for the program.

• 330K adults in Kentucky HEALTH
• 138K already meet requirement
• 48K don’t meet requirement and are not likely to be deemed “medically frail”

What the study tells us about the 48,427 who do not currently meet the requirement: Of the 1074 Medicaid beneficiaries interviewed...

• 27% reported poor or fair health
• 25% reported poor or fair mental health
• 33% reported that usual activities were limited by a health condition in

the last 30 days

(Venkataramani et al, JAMA Network Open. 2019)

Impact on Community Health Centers

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A new analysis by researchers at Milken Institute SPH finds that...

• 86K - 136K would lose coverage

in just the first year of the work requirement

• 4 in 10 adult Medicaid patients

served by health centers would lose coverage

• Loss of $23-37M in Medicaid

revenue

• 10% decline in health center

capacity for patient care

Impact on Hospitals

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Based on SNAP enrollment losses tied to work requirements, an analysis by the Commonwealth Fund found that if Kentucky HEALTH has been implemented in 2019, it would have led to:

• 108-118,000 losing

Medicaid coverage

• 19-21% decrease

in Medicaid revenue/hospital

• 2X increase in

uncompensated care

Using Exemptions to Protect Vulnerable Kentuckians

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■ Who is “medically frail”? It depends how you interpret the definition:

• Disabling mental disorder
• Chronic substance abuse
• Serious medical condition
• Difficulties with activities of daily living
• Retirement, Survivors, Disability Income (RSDI) due to a disability
• Chronic homelessness
• Survivor of Domestic Violence

■ How are people determined MF?

• Automatically through an algorithm
• Manually through a provider attestation

■ CHFS data for MCO RFP: July 2017 - June 2018

• Medically Frail (through algorithm): 61,581
• Potentially MF (requires attestation): 41,484

The Limitations of Exemptions

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• 1. The exemption process is complicated and opaque.

■ The algorithm is proprietary ■ 40% aren’t automatic and require annual paperwork ■ MCOs are heavily fined for approving too many attestations

• 2. Exemption criteria doesn’t include all conditions that make it difficult for an

individual to meet onerous work reporting and cost-sharing requirements.

• 2. SUD exemption is backward, making it difficult to be determined MF unless you

are already in in-patient treatment or have a co-occuring disorder.

• 2. System issues impact everyone.

■ State workers get spread thinner with more administrative red tape ■ Exemptions don’t provide sufficient guardrails to protect from system failures

Work Programs the Right Way

Paths 2 Promise: Kentucky recieved a $19.9M grant to operate a SNAP demonstration program in the Southeast Kentucky Promize Zone, including Bell, Harlan, Clay, Letcher, Knox, Leslie, Perry, and Whitley Counties. Participaton was completely voluntary, but provided support services similar to the K-TAP program, including a team of case managers, transportation and childcare assistance, and access to education and training programs.

Whitley County Clay County Perry, Letcher, Leslie Counties Knox County Harlan County Bell County

Work Programs the Right Way

Washington State SNAP Employment and Training program

❏ Partnerships with education and training providers to draw

down more federal dollars

❏ Expanded budget by millions of dollars ❏ Expanded supports to help continued participation ❏ Not a requirement for continued receipt (except for non-

waivable ABAWD counties)

❏ Other states have emulated Washington State...Kentucky can,

too!

Smart Investments for Kentucky

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Recommendations across programs

• Incentivize upward mobility by bridging the benefits cliff and encouraging households to

save for big expenses or emergencies, like repairing a home or buying a car.

• Leverage existing opportunities to match all available federal funds.
• Reduce administrative red tape, burdensome reporting, and complicated exemptions.
• Adopt an Affordable Housing Tax Credit.

Recommendations for SNAP

• Expand work supports, like those used in the successful Paths 2 Promise pilot program:
• Childcare
• Transportation
• Internet access
• Education and job training
• Maximum SNAP “double dollars” to increase access to healthy foods, support local

farmers, and reduce food deserts

• Remove the SNAP bans for drug felons and parents behind on child support

Smart Investments for Kentucky

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Recommendations for TANF

• Remove the "deprivation factor" of death, absence or incapacity and require only that

kids be in low-income households

• Improve outdated earned income disregards to allow people to keep more of their

earnings

• Raise the $2,000 asset limit for TANF cash benefits or eliminate it completely

Recommendations for Medicaid

• Create a “bridge plan” to keep health insurance affordable for low-income workers

making 138% - 200% FPL

• Create a 1915c Medicaid waiver to provide housing and mental health services for 16+

Questions?

emily.beauregard@kyvoicesforhealth.org jason@kyvoicesforhealth.org kyadvocacy@gmail.com