VIEWPOINT: Medicaid work reporting requirements simply don’t work

Guest column by Sarah Graves, American Cancer Society Cancer Action Network

A year ago, South Dakota voters initiated and overwhelmingly approved Amendment D, expanding Medicaid coverage to more than 50,000 residents who did not previously qualify.

 Those folks fell into the coverage gap, with incomes above the state’s Medicaid eligibility level but also just barely above the poverty line, meaning they could not afford marketplace plans. What Medicaid expansion meant for people in the gap, in a practical sense, is that they no longer were forced to forgo basic medical care to cover rent, food, childcare or other basic needs. 

It was – and is – a massive victory for the entire state, but especially to those who can now access health care. Regular health care visits and access to preventative screenings lead to earlier discovery and better treatment options for cancer and other life-threatening diseases and chronic conditions. It also means people can live healthier, happier lives and – yes – go to work. 

VIEWPOINT: Making Medicaid Expansion a pathway forward

I did not need the coverage. I am insured and employed in a medical office. I was a volunteer, a voice and an advocate for Amendment D because I know how easily lives get turned upside down by a lack of coverage. I learned this when I was diagnosed with cancer while building a small business. I did not have insurance and it was a life-changing, scary experience nobody should be forced to endure. 

Thankfully, when voters made themselves heard at the polls in November 2022 and Medicaid expansion was implemented in July, more than 12,000 South Dakotans have now enrolled despite a difficult communication climate in which many of those eligible don’t know benefits exist. Many do not realize they need coverage until they get a diagnosis that often leads to difficult health and financial outcomes. The truth is, nobody can fully understand the scope of a cancer journey until they or a loved one has lived it. Health care issues are often not easy to comprehend.  

That’s why well-intended but deeply flawed ideas can sound like common sense – like placing work reporting requirements as a condition of Medicaid coverage. 

The central issue with work reporting requirements is – unlike South Dakotans – they do not work. At least not how they are intended. When similar requirements were put in place in Arkansas, 25 percent of those on Medicaid lost coverage, not because they declined to work, but because of burdensome paperwork. 

Only 51 percent of state employers offer health benefits. Nearly all our people work -- and work hard -- and many of those jobs don’t give them access to health care. South Dakota’s work ethic is not a problem. State unemployment is 1.9 percent, second lowest in the nation, and the percentage of residents who work two or more jobs is the nation’s fifth highest. What work reporting requirements clearly would do is require a significant amount of government-mandated paperwork be done by people who are already working hard just to get by. 

Unquestionably, some South Dakotans who are fully eligible, fully employed and doing all they can to support themselves and their families will lose coverage. Some will have to stop working because of their illness, lose coverage and certainly face diminished health outcomes and worse. Medicaid expansion is meant to be a stepping stone when someone is in need. When expansion was enacted in Montana, the average enrollment period was two years. A third of enrollees needed it for less than a year. 

Perhaps the most damaging unintended consequence of work reporting requirements is that they clearly would harm an entire group of South Dakotans who certainly are working full time, just not how we immediately think about it. Those struggling with illness and their caregivers are often unable to fulfill employment, so are perhaps not punching the clock at a construction site or stocking store shelves, but their labor is inarguable and crucial to their future and our communities. Working full time while receiving cancer treatment drained me. I maxed out my sick time, struggled to get through the workday and was too fatigued at the end of the day to care for my daughter. Fighting cancer is hard work. I didn't have Medicaid expansion as an option, and I'm so grateful to South Dakota voters for giving our friends and neighbors this lifeline. 

No system is infallible. Medicaid expansion certainly will need to be monitored and maintained and, thanks to federal support, the people are in place to do that. It will take a bit longer than five months to see a full picture of the positive effects of improved health care access in South Dakota, but the current state of affairs is promising: Fewer people are uninsured. Data shows South Dakotans are clearly working. And Medicaid expansion – as it was put in place by the voters – helps make this possible.  

Sarah Graves is a Pierre resident. She works in a medical clinic while she attends nursing school and is a volunteer with the American Cancer Society Cancer Action Network.