A Cancer Diagnosis May Not Excuse You From Work

A cancer diagnosis used to be enough to qualify as medically frail and exempt from Medicaid work requirements. A new federal rule says it no longer is, and nobody has defined what will be enough instead.

In this clip from our episode “The Hidden Cost of Medicaid Work Requirements”, hosts David E. Williams and John Driscoll break down the last-minute rule change narrowing the definition of medical frailty and why 25 states say the federal government has gone beyond what Congress ever authorized.

Listen to the full episode here

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CareTalk is a weekly podcast that provides an incisive, no B.S. view of the US healthcare industry. Join co-hosts John Driscoll (President U.S. Healthcare and EVP, Walgreens Boots Alliance) and David Williams (President, Health Business Group) as they debate the latest in US healthcare news, business and policy.

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Transcript

David: 0:07

There is something new b- besides just the fact that rules are coming out and, and this is gonna go into effect, which is a new rule that narrows the definition of medically frail. So a person, let's say, with cancer, with HIV, has been considered exempt from needing to work, the same way someone who's pregnant or disabled or, um, you know, caring for young children has been exempt. And what's this rule is doing is it's saying it's no longer enough to go into the electronic medical record and say the person's being treated for cancer and therefore they have cancer and they're exempt. They now have to, uh, document it in some other way, which isn't defined, and the states are arguing this has happened at the last minute when the informal guidance had not suggested that at all.

John: 1:01

Yeah, I think, I think that the, you know, it's important to acknowledge that this is, this is gonna affect all of the substantial coverage that was created in the med- in the 41 Medicaid expansion states, and that there are exceptions for this wor- 80 hour, 80 hour a month requirement for, um, pregnancy, caregiving for young children, um, s- d- disability, addiction treatment, people meeting the, the current food stamp or SNAP and TANF requirements. And they had indicated medical frailty. I do think that that is a, to your point, an undefined term, and as they've gotten closer and closer to the end of the year, have come up with this new definition that I think is, uh, I still think is somewhat imprecise, the way I read it, and certainly is a narrower lane than the initial enabling legislation suggested. Uh, but I think this whole thing is gonna be complicated to implement, frankly. And I don't, and I don't know that we've got a path. I mean, th- there's a lot of focus on this medical frailty piece, but I think a lot of states aren't ready for the January 1 implementation. Um, but let's stay on the medical frailty piece. You know, to a, um-- You know, it's not a term of, of, uh… It's, it's more of a term of art than science, and I think what, what the federal government realized is that if, uh, they really wanna push this m- uh, work requirement piece, they had to be more precise, and I think they just got there later in the year, and I think that's triggered, um… I think it's-- How many states are suing them now t- on, on this term? Is it about 18?

David: 2:43

It's 20-- It's 25 states- Oh … plus the District of Columbia.

John: 2:48

Yeah. Amazing.

David: 2:50

So it's a lot. You know, and John, I think, you know, to be-- I don't wanna say to be fair because I don't think we ever promised to do that, but in order to, to give an argument that would be accepted by more people, you could look at it and say, okay, if you just put medical frailty, well, that's just like a big exemption and you could claim you're frail for, you know, for whatever reason. I think the challenge is it's not that they've defined it more precisely. They've just said it's not enough to use the documentation that they had previously said was legitimate. And the basis of the lawsuit is that the administration is going beyond what was legislated and that they're therefore, uh, violating, uh, certain laws, uh, that exist, uh, in order to prevent that. So there's the, the Administrative Procedure Act and then just the spending clause of the Constitution. So they're saying you're just not allowed to do what they're doing. That's the essence of the lawsuit.

John: 3:47

Just to be clear, it was, I believe, his, i-i-initially the informal guidance was if you can show that you're medically frail through a documented medical record through a credible medical claim, that, that you could show that you were, you know, too sick to work ef-effectively. And now there is, I think, an external requirement that says it's not, it's not enough that historically you can show that you're-- I'm just gonna s- you use a more conventional phrase of too sick to work, that you have to prove your medical frailty. But I'm not sure it's exactly defined.

David: 4:20

No, it isn't. It isn't, John. And that's, and that's part of the point. So, and, and this gets back to also what, what happens. So the states have been trying to, uh, you know, mitigate the effect of this. In other words, they're trying to make it so that people that are legitimately eligible, uh, stay insured. And so they spent a lot of time putting together eligibility systems. They're drafting notices to members. They've been hiring staff. And then-- and they f- they, by the way, they f- they face financial penalties if they don't hit the deadline. So they've, they've definitely been on top of it and they're saying, whoop, there's this rule change now with weeks to spare and it's not gonna work for them. Now, what has worked w- w- and generally where you see these changes is good sort of customer service, lead time, peer support, clear communications, and states that are trying to do that are finding, oh, they're being cut off.