Red states ravaged by the opioid crisis are pushing for Medicaid work requirements that could push people out of treatment as they try to get off drugs.

Kentucky, New Hampshire, Maine and Indiana are among at least eight GOP-led states seeking federal approval to require Medicaid enrollees to work as a precondition of their health coverage. All four states have been hard hit by drug addiction, which claims 140 lives a day nationally.


Governors say they would exempt people with chronic drug problems or severe mental illness from the Medicaid work requirements, but who would qualify and under what circumstances hasn’t been spelled out. Critics fear that many addicts could lose benefits, particularly if they go in and out of treatment, or have relapsed — a not uncommon occurrence. Employers’ resistance to hiring people who have failed drug tests or have criminal records could also put health benefits at risk.

Backers of Medicaid work requirements say they're needed to reduce government dependency as the program has grown to cover more than 70 million Americans — nearly 12 million of whom obtained coverage under Obamacare.

The Trump administration is sympathetic, signaling it will sign off on the state waiver requests, even as it made combating the opioid epidemic a priority.

Prescription Pulse A weekly briefing on pharmaceutical policy news — in your inbox. Email Sign Up By signing up you agree to receive email newsletters or alerts from POLITICO. You can unsubscribe at any time. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

But even some Republican state lawmakers say they fear those with addiction issues would fall through the cracks.

“I’m all for designing programs in a way that encourages and rewards work,” said Indiana state Rep. Ed Clere, a Republican who has previously bucked party leaders. “But we have to be careful not to let that objective undermine the primary purpose of health care, which is improved outcomes and wellness. I wouldn’t want to see a work requirement get in the way of positive behavior modification and the individual’s ability to take responsibility for his or her own health.”

Indiana, which expanded Medicaid coverage to 400,000 people under then-Gov. Mike Pence in 2015, is one of the states asking for federal waivers to impose Medicaid work requirements that are primarily targeted at working-age, able-bodied adults. Officials generally are seeking to mandate 20 hours per week of work, or participation in a job-related activity, including volunteering or training.

Low-income adults in treatment for substance abuse would be exempt from the requirement, yet state data show that only slightly more than a quarter of enrollees with diagnosed problems are getting treated. Death rates stemming from drug abuse in 2015 stood at 19.5 per 100,000 residents, according to the Centers for Disease Control and Prevention.

“There’s a lot of people who don’t seek treatment who have challenges,” said Matt Brooks, president of the Indiana Council of Community Mental Health Centers and chairman of the state’s Medicaid Advisory Board. “There are folks who might need services that miss out.”

Spending on substance abuse and mental health treatment grew substantially after states expanded Medicaid coverage to low-income adults, with Medicaid spending over $7 billion on substance use disorder services in the first year of Obamacare’s expansion, in 2014, according to the Kaiser Family Foundation. The program’s spending on mental health care that year was approximately $46.5 billion.

Niki Campana stands in front of the Neil Kennedy Recovery Clinic on June 15 in Youngstown, Ohio. | David Dermer/AP Photo

Kentucky — whose request to impose work rules on able-bodied adults was not acted upon by the Obama administration — is expected to be the first state to receive the Trump administration’s blessing. Officials estimate that roughly 95,000 people over a five-year period would lose Medicaid benefits under Gov. Matt Bevin’s proposal, which also includes increased premiums and other restrictions.

Still, Bevin says the idea of mandating someone with addiction problems to work “doesn’t make sense.” Kentucky had the third highest rate of death due to drug overdoses in 2015, clocking in at 29.9 per 100,000 people.

“This isn’t intended to be just a one size fits all, black and white, you do it this way or you don’t get it,” he told POLITICO during a recent Republican Governors Association conference in Austin, Texas. “That’s foolish. A person like that is a true detriment to themselves, to their families and society as a whole in their addicted state. We need to get them to point where they are not in [an] addicted state so they can become an asset to themselves and their family and society.”

The state intends to exempt Medicaid enrollees from employment rules and other conservative changes if they are deemed “medically frail,” a catch-all term for people with serious conditions. Indiana includes a similar exemption.

Yet many of the details in the plans are hazy. In Kentucky, some of the qualifying conditions to be deemed “medically frail” are automatic, such as being diagnosed with HIV/AIDS, being eligible for Social Security Disability Insurance or receiving hospice care. Others — such as having a chronic substance use disorder or disabling mental health issue — would meet the definition only if they satisfy yet-to-be-determined criteria.

People with addiction issues face a number of hurdles to obtain employment, including employers that drug test their prospective employees. More than half of all employers require job candidates to take drug tests, according to a study by the Society for Human Resource Management. Relapse is also common. Nationally, the National Institute on Drug Abuse estimates that relapse rates for addiction range from 40 percent to 60 percent.

“People cannot get a job because they can’t pass a drug test,” Brooks said. “So now, not only can you not get a job because of a substance use disorder, but you’re not going to have access to health care ... and then where does that leave you?”

How can we solve the opioid crisis? Sarah Karlin-Smith, health care reporter for POLITICO, explains the opioid crisis, and how America can change it's practices and policies to help bring the crisis to an end.

Criminal records for drug offenses can also make it harder to find employment. Though companies are legally prohibited from having blanket policies against hiring ex-offenders, it can be more difficult for those with a criminal history to find work.

Beyond finding work, people struggling with opioid abuse have trouble maintaining the sort of stability that enables them to hold down a job.

“This is a disease that hijacks a person’s brain,” said Mark O’Brien, vice president of state and local affairs for the Addiction Policy Forum. He added that for those in treatment programs, getting care can be time-consuming. “For some people, getting treatment is a full-time job,” he said.

New Hampshire’s waiver proposal would exempt anyone with a mental or physical illness or disability if their doctor fills out a form to verify their eligibility. People participating in the state’s drug court program are also exempt from work requirements. However, it’s unclear whether doctors would need to fill out the form only once for their patients or would routinely be required to certify that a Medicaid-eligible person still qualifies for the exemption.

“We’re not trying to leave anybody out,” said New Hampshire state Senate Majority Leader Jeb Bradley.

Renuka Rayasam contributed to this report.