Work Requirements are Uniquely Challenging for Those with Mental Health Needs

This is part of TCI’s report: Work Programs Should Help, Not Harm, Virginia Families: Thousands Likely to Lose Coverage under Waiver

In the four states that were approved as of October 2018 to tie work requirements to Medicaid — Arkansas, Indiana, Kentucky, and New Hampshire — people identified as “medically frail” are exempt from meeting the new requirements (Kentucky’s approval has been repealed by a Federal District Court and is back to CMS for reconsideration). Virginia, like the other states, will also exempt people who are “medically frail” and those who have a serious mental illness or a disabling mental disorder. However, those with various forms of mental illness that are considered to have acute medical conditions are not exempt. Individuals with mental illness who are on Medicaid are much more likely to not be working and have unique challenges for finding and sustaining employment.

Even if a person has a severe mental illness that should exempt them from work requirements, there are significant barriers to proving it. To start, people with mental illness would need to gather letters from their health care providers, medical records, and possibly other documentation Virginia deems necessary. Additional paperwork has been shown to reduce Medicaid enrollment, and someone struggling with mental illness would likely have even more trouble gathering all the required items. An uninsured person who may newly qualify for Medicaid under expansion and has mental illness might not have the chance to see a doctor to get a diagnosis which would exempt them from meeting the work requirements.

Beyond administrative barriers, individuals with even acute mental illness often face other employment challenges. People with mental illness can have periods where they are less functional, which can impact their ability to sustain employment or may cause unexpected job loss. This would make it difficult for individuals going through a rough patch to meet the 80 hour a month threshold for work requirements and could cause them to lose health coverage when they most need it. For many people with mental illness, they may be able to work full-time when they are not experiencing symptoms, but if they do experience symptoms that disrupt work periodically, they may be suspended from their health coverage.

Furthermore, people with mental illness are disproportionately likely to fall into the criminal justice system and struggle to find employment as a result. Evidence shows that these barriers can be mitigated when individuals with mental illness have access to job search assistance, job coaching, and counseling. Yet, given the meager amount of money allocated in the budget to support work requirements, it seems unlikely that any resources will be available for such services and people with mental illness will face one more barrier in their lives.