Now that House Republicans have squandered their shot at reordering Medicaid, governors who want conservative changes in the health program for low-income Americans must get special permission from the Trump administration.
Near the front of the line is Wisconsin Gov. Scott Walker, a Republican who not only supports work requirements and premium payments but also a new additional condition: to make applicants undergo a drug test if they’re suspected of substance abuse.
If Walker gets his way, Wisconsin would be the first state in the country with mandatory drug screening for Medicaid enrollees. The governor plans to release his proposal in mid-April and submit it to the Department of Health and Human Services by the end of May.
The approach — which also would mandate treatment for those testing positive — aligns with the goals of several Republican governors intent on tightening the program’s rules. Although the Obama administration allowed them to place expectations on enrollees, they’re hoping for far more leeway from HHS Secretary Tom Price.
The goal behind Walker’s proposal “is to help people get healthy so they can get back in the workforce,” said Julie Lund, communications director for the Wisconsin Department of Health Services.
Yet states that have started screening their welfare applicants over the past few years have turned up few drug users. In North Carolina, less than 0.3 percent of applicants to its WorkFirst welfare program tested positive for drugs during a five-month period in 2015. Michigan didn’t find any welfare recipients abusing drugs during a year-long pilot program in 2016.
Opponents of Walker’s idea say the data shows that drug testing for Medicaid applicants isn’t worth the cost and effort.
“They haven’t turned up much use of drugs among that population,” said Jon Peacock, research director for the Wisconsin Council on Children and Families.
Republicans have long wanted to overhaul the Medicaid program, frustrated by its growing costs to states and provider shortages. The Affordable Care Act replacement backed by House Speaker Paul D. Ryan (R-Wis.) would have cut federal Medicaid spending by allotting it to states on a per capita basis, but that plan folded late last month amid insurmountable differences between conservatives and moderates.
Under President Barack Obama, the Republican-led states that accepted the ACA’s Medicaid expansion got permission through waivers to shape their programs in alternative ways. His administration allowed them to place extra responsibilities on new enrollees, though it stopped short of work requirements.
Patients in Arkansas, Indiana, Iowa, Kentucky, Michigan and Montana must pay part of their monthly coverage premium. Two dozen states require some cost-sharing, up to 5 percent of household income, for certain care.
With President Trump in office, that approach looks more promising than ever to Republican governors. Indiana, Arizona, Kentucky and Pennsylvania have requested to make work a condition of Medicaid eligibility, while Arkansas has said it will submit a proposal to the new administration.
Red states have good reason to believe they’ll be successful. Earlier this month, Price and the new head of the Centers for Medicare and Medicaid Services indicated in a letter to governors that proposals related to “training, employment and independence” would be welcome.
Yet it’s less clear how the administration will react to Walker’s request for drug screening. While applicants would be tested only if they’re reasonably suspected of using drugs, the requirement could appear hostile at a time when Trump and Republicans are trying to appear more sympathetic to the problem of drug addiction.
Trump tapped New Jersey Gov. Chris Christie (R) to lead a new commission on drug addiction and urged more focus on the problem at a White House forum Wednesday. “This is a total epidemic,” Trump said.
Health advocates in Wisconsin, who are generally opposed to Walker’s idea, point to the underwhelming results from applying testing to welfare programs. They also raise concerns that it could increase stigma about drug abuse and the poor. While some research has shown higher rates of drug abuse among low-income Americans, experts are divided on how big the difference is and stress that it’s a problem afflicting people at all income levels.
“We’re singling out lower-income people, playing on stereotypes, on the premise that somehow people on Medicaid are getting something they shouldn’t be getting,” said Robert Kraig, executive director of Citizen Action of Wisconsin.
Health advocates also note that requiring Medicaid enrollees to get treatment for substance abuse doesn’t guarantee they’ll be able to find a provider in Wisconsin, which like many states has a shortage of doctors willing to accept Medicaid’s lower reimbursements.
“This is a simplistic response to a far broader problem,” Peacock said. “Wisconsin and, I think, many other states need to invest far more in effective treatment and prevention programs.”
Walker did include in his bundle of Medicaid proposals one provision health advocates like: at least partial coverage of residential treatment for substance abusers. But they’re hesitant to give the governor much credit, since they’ve long bristled at his refusal to accept the extra federal funding with Medicaid expansion.
The best way to get treatment for drug abusers is to expand Medicaid, not require screening as a prerequisite for enrolling, said Judy Solomon, vice president for health policy at the Center on Budget and Policy Priorities.
“It’s a sound bite as far as I’m concerned, without any evidence,” she said.