Why 250,000 Washington residents might lose their Medicaid next year

On a recent Friday, 41-year-old Kevin Wren was exhausted, drinking apple juice to raise his blood sugar.

“I’m not sweating anymore, so that’s great,” he said in his dining room overlooking a steep street in Seattle’s upper Fremont neighborhood. “I’m feeling better.”

Wren, who lives with his parents and his dog Mocha, has Type 1 diabetes. He’s too sick to work much — he manages about five to 10 hours, and makes about $300 a month. There have been times when he went to the hospital several times a week; a time when he was in a coma for two weeks; a time when he was in the ICU for three months. High blood sugar has destroyed his eyesight, so he can’t drive. One of his toes has been amputated.

When the new work requirements for low-income people on Medicaid start in January, Wren said, “I’m afraid of being denied.”

In the 40 states, including Washington, that expanded Medicaid eligibility under Obamacare, people can get health insurance through Medicaid if they make less than 138% of the federal poverty level. For a single adult like Wren, that’s an annual income of about $22,000.

Starting in 2027, when their Medicaid comes up for renewal, they’ll have to file paperwork proving that they work, volunteer, or go to school at least 80 hours per month, or that they qualify for an exemption. If not, they’ll lose their health coverage. This work requirement came down from the federal government, as part of HR1, sometimes referred to as the “Big Beautiful Bill.”

In Washington, more than 600,000 people will be subject to the new requirements, and state health insurance administrators estimate that about 250,000 of them will lose their Medicaid and become uninsured. Many of those who could become uninsured do already work, or qualify for an exemption, but they might struggle to keep proving that every six months.

Washington state Sen. Chris Gildon, a Puyallup Republican, said he supports the new work requirements.

“Philosophically, I believe that if someone is able to work, that they should be working,” he said.

Gildon said this change will bring Medicaid more in line with other needs-based benefits, like food stamps, which already have work requirements. And he thinks it will inspire some people to get jobs, and will therefore save money and help alleviate the state’s budget shortfall.

“What we don’t want is people to become dependent for a lifetime on public benefits with no way to rise above,” he said.

But critics of the policy say it won’t help people get jobs. It will just cause them to lose their health care.

They point to Arkansas, which instituted work requirements in 2018. Research found that people there lost coverage not because they weren’t working, but because they had trouble keeping up with documenting and reporting their work hours to an additional agency.

Exemptions from work requirements

Many low-income Medicaid recipients are exempt from the new requirements: people who are pregnant or in their first year after having a baby, people in treatment for or recovering from addiction, people who serve as caregivers of dependent children under 13 or of someone with a disability, and others.

Ryan Moran, CEO of Washington’s Health Care Authority, is the person responsible for rolling out the new Medicaid requirements in Washington state. He said his agency has had to hire about 100 more people, since they’ll now be reviewing renewal paperwork for Medicaid recipients every six months instead of every year, in addition to determining people’s compliance with work requirements.

Moran said the state is working hard to keep as many people insured as possible.

“HR1 puts an enormous amount of barriers in individuals’ way,” he said. “Our goal at the moment is to try to remove as many barriers [as] possible.”

Moran said his agency has spent $100 million of state and federal funds to build systems that will automate renewals for as many people as possible. If the state already knows someone just had a baby, for example, the system will pull in that information rather than asking them to fill out more paperwork to keep their Medicaid.

But Moran said there’s one exemption that will be impossible to automate, and that’s for people who are “medically frail.” People like Kevin Wren who are too sick to work will not, in theory, have to — but they will have to somehow prove their frailty.

Moran was hoping that just having certain diagnoses would qualify people for the “medically frail” exemption, because that would be something Washington could automate, but the federal government told the states: A diagnosis alone is not enough.

“Whether it’s cancer, whether it’s HIV, some of these conditions that absolutely we would classify from our clinical experts as medically frail — just relying on that diagnosis is not enough,” Moran said.

It’s not clear what evidence or paperwork people will have to produce to prove their frailty, Moran added.

Becoming uninsured

When people lose their insurance, they tend to stop going to preventative primary care visits, where their doctor can manage any chronic conditions they have, such as diabetes, high blood pressure, or chronic heart problems.

“When that preventative type of medicine is not occurring, those problems get worse, and they get worse in a hurry,” said Dr. Steve Mitchell, interim chair of the Department of Emergency Medicine at the University of Washington.

“[When] the patients…get sick — truly sick — they come to the emergency department,” he said.

Mitchell said that puts pressure on already busy ERs.

“Sadly, we do run out of space, and so a lot of care is provided in the waiting rooms of emergency departments,” he said.

People who are uninsured generally can’t pay their emergency room bills, so the hospital usually writes it off as “charity care,” which means more strain on hospital finances, and sometimes closed departments — departments that are closed for everyone, not just Medicaid patients or the uninsured.

“What’s incredibly frustrating and sad for us is that we know that so many of the horrific problems that people are having can be prevented should they have access to a primary care doctor,” Mitchell said.

Eilís O’Neill is a reporter with KUOW. This story comes to you from the Northwest News Network, a collaboration between public media organizations in Oregon and Washington.

It is part of OPB’s broader effort to ensure that everyone in our region has access to quality journalism that informs, entertains and enriches their lives. To learn more, visit our journalism partnerships page.