Trump Administration Shunts Data Collection and Research on Medicaid Work Requirement

Published Mar 20, 2019

The CMS has approved numerous state plans to implement a work requirement for Medicaid participants.

What happened: The Centers for Medicare and Medicaid Services (CMS), located under the Department of Health and Human Services (HHS), has approved numerous state plans to implement a work requirement for Medicaid participants. However, a majority of these plans lack the ability to collect baseline and evaluation data on Medicaid participants. These data are required to be gathered under federal regulations in order to assess how the number of Medicaid enrollees may change as the result of the new initiative and to evaluate whether the new initiative is successful or not at implementing its goals.

Why it matters: Collecting data and carrying out research is a crucial part of determining whether a policy is effective in the real world. One of the pillars of scientific ethics is the principle of beneficence, which requires that clinical research be designed to maximize the benefits while minimizing the harm to study participants. One prominent example of beneficence is stopping a research project if the harms to individuals prove too great, and this can only be achieved by collecting and analyzing baseline and evaluation data. Failing to collect data shows that the Trump administration is failing to consider the potential risks and harms that may befall low-income Americans on Medicaid.

The Trump administration is sidelining science by refusing to collect data and conduct analyses on a new policy that requires Medicaid recipients to prove they are employed. By sidelining the collection of commonsense data and failing to carry out preliminary analyses, the Trump administration is essentially shutting out any objective way to assess a health policy, a policy of which is already having a disturbing impact on the low-income Americans that depend on Medicaid for their health and even their lives. Refusing to collect this data is also a refusal to enforce federal rules that stipulate states must assess the impact of new initiatives like that of the work requirement for the Medicaid program.

The Los Angeles Times conducted an analysis on the Department of Health and Human Services’ (HHS) new Medicaid work requirement and they found that the Trump administration is failing to enforce federal rules that direct states to collect data that assesses the impact of new initiatives like the work requirement. Specifically, two types of data are not being collected: baseline data, which would have estimated effects on Medicaid coverage before the initiative started; and evaluation data, which would have provided metrics on whether the work requirement helped carry out the program’s goals. Eight states have been cleared by Centers for Medicare and Medicaid Services (CMS) to implement a Medicaid work requirement; however, none of the eight states have a plan in place that allows the collection of evaluation data to determine whether the new initiative will lead participants to find jobs or improve their health. In addition, nine states have been allowed by CMS to proceed with their applications despite failing to calculate the number of people who could lose Medicaid coverage under the new work requirement.

In health science, baseline and evaluation data are essential pieces of information to have in order to assess whether a health intervention was successful or not. Without these types of data, it is difficult to monitor the situation, to track changes, to determine the impact of an intervention, to evaluate whether the intervention is safe and effective, and to set future targets. Furthermore, a new health intervention is always implemented with a goal in mind, which CMS dictated in their press release is to “to improve Medicaid enrollee health outcomes by incentivizing” work requirements. Without collecting the data, it will be nearly impossible to assess whether improved health outcomes for Medicaid enrollees occurred as a result of the newly implemented work requirement.

In response to this, a CMS spokesperson claimed not only that “precise numerical estimates of coverage impacts” are “difficult to predict in many types of demonstrations” (demonstrations here mean health experiments involving Medicaid participants), but that “transparency regulations do not require that states provide” these type of data. This is not supported by the evidence. Federal regulations from 2012 stipulate that requests from states seeking to implement a new Medicaid experiment are required to develop plans for independent evaluations. The design of these evaluations must include “monitoring and reporting on the progress towards the expected outcomes” of the experiment’s hypothesis and “the baseline value for each [data] measure” used to evaluate the Medicaid experiment. The regulations further specify that states are required to carry out a preliminary analysis to provide “an estimate of the expected increase or decrease in annual enrollment” as a result of carrying out the experiment, or the state’s application “will not be considered complete.”

Health policies have far-reaching effects on people’s health. Already Arkansas, the first state granted permission to implement a Medicaid work requirement (despite the lack of an approved research plan), has already removed more than 18,000 people from Medicaid coverage for failing to comply with its work mandate. Health policies warrant a rigorous scientific evaluation in order to assure that they are safe and effective and the Trump administration’s failure to carry out these evaluations is causing harm to low-income Americans.