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    This letter is being sent to the federal government by Mary B. Sellers, U.S. President of United Way Worldwide, on behalf of the people of Tennessee. It's objective is to stop the expensive, inefficient, and harmful work reporting requirement that could cause 68,000 Tennesseeans, mostly children, to lose their medical coverage through TennCare. 

    Adding work reporting requirements to TennCare/Medicaid will take health coverage from parents, children, veterans and families, will needlessly burden employers and employees, and will waste taxpayers’ money.

    You have until February 7, 2019, to submit public comments opposing these requirements. Answer this short survey, and your response will be submitted to state and federal officials:


    7 February 2019

    The Honorable Alex Azar, Secretary

    U.S. Department of Health and Human Services

    200 Independence Avenue, SW

    Washington, DC 20201


    RE: TennCare II Demonstration Amendment 38


    Dear Secretary Azar,

    United Way Worldwide appreciates the opportunity to comment on Tennessee’s 1115 Demonstration Waiver amendment. United Way brings together the caring power and resources of over 1125 local communities across the United States, and in 41 countries across the globe. Together, we fight for the health, education and financial stability for every person in every community.  Access to affordable, quality healthcare is a critical building block for people to lead successful lives and is core to our work in communities. 

    Medicaid and It’s Objective

    Medicaid is our nation’s health insurance program for low income individuals, including children, seniors, people with disabilities and veterans. As reaffirmed by a recent court ruling, prior to approving an 1115 demonstration waiver, the Secretary must ensure the project promotes the objectives of Medicaid, which is to furnish medical assistance, rehabilitation, and other services designed to help individuals retain a capacity for independence.[1]

    Work Requirements Should Not Be Required as a Condition of Medicaid Eligibility

    United Way supports work as a core American value, and the main way to provide for our families and bring dignity to our daily lives. Access to affordable healthcare is both a precursor to and critical support for an individual’s ability to work. An issue brief by the Congressional Advisory Committee, MACPAC, explains in detail how Medicaid, as the nation’s health insurance program for low income Americans, supports work for beneficiaries.[2] Low-income adult Medicaid enrollees have high rates of chronic conditions and mental illness. When conditions like diabetes, heart disease or depression are treated and controlled, individuals with these conditions can hold steady employment. 

    Tennessee’s Proposal Would Cause Very Low-Income Parents to Lose Medicaid Coverage

    Tennessee has not taken up the Affordable Care Act’s (ACA) expansion of Medicaid that covers newly eligible parents and other adults with incomes up to 138 percent of poverty. Instead, it covers only the parents, with incomes at or below 98 percent of the poverty line. The state’s application does not provide an estimate of the impact of the proposal on enrollment or the number of parents who will lose coverage as the result of the proposed work reporting requirement. We believe the application is incomplete without this information given that coverage is a central objective of the Medicaid program.

    The proposal says only that “some number of individuals may transition off of TennCare and into other coverage options as their earnings increase; however, it is not possible to reliably project the magnitude of this decrease in enrollment at this time.” It does not even state how many parents are currently enrolled in TennCare, much less how many would be exempt from the requirements and, of those not exempt, how many would be likely to lose coverage. As discussed below, there is mounting evidence that reporting requirements, red tape, and other administrative burdens cause significant coverage losses. Most parents who lose coverage would immediately become uninsured, regardless of whether they remain in poverty, and regardless of their need for medical care.

    Tennessee proposes to take Medicaid coverage away from parents age 19 to 64 with incomes at or below 98 percent of the federal poverty line (about $1742 per month for a family of three in 2019) who don’t meet a work reporting requirement.

    Tennessee’s proposal is harsh. The state would take coverage away from parents in poverty who do not meet the work reporting requirement with limited exceptions, such as for those with a child under the age of six, or those who are pregnant, have a disability, or are certified as “physically or mentally unfit for employment.”

    Evidence from Arkansas Suggests That Many Beneficiaries Could Lose Coverage Because of Tennessee’s Proposed Work Reporting Requirement

    Arkansas is the first state to implement Medicaid work reporting requirements, and the experience of Medicaid beneficiaries there demonstrates that Tennessee’s policies will lead to substantial coverage losses, without any demonstrated increase in employment. The state determined that more than 80 percent of beneficiaries qualify for an exemption and don’t have to report work or work-related activities to stay covered. Of the beneficiaries who had to report, many did not claim an exemption or could not satisfy the reporting requirement.[1] As a result, nearly 18,000 Arkansans have lost Medicaid coverage to date, with further coverage losses likely in coming months.

    It’s clear from the first six months of Arkansas’ implementation of a demonstration that takes coverage away from people who don’t meet a work reporting requirement, that these policies don’t lead to employment for those who can work and that they jeopardize coverage for beneficiaries who are working or should be exempt because they can’t work. Since September 1, 2018, Arkansas has terminated coverage for over 18,000 Medicaid beneficiaries — or 23 percent of those subject to the work reporting requirement.[1] If Tennessee has a similar outcome, approximately 68,000 parents will lose their Medicaid coverage in Tennessee, according to a report by the Georgetown Center on Children and Families.[2] 

    Far more Arkansans are losing Medicaid coverage than are in the presumed target group of people not working and ineligible for exemptions, which means people who should remain eligible are losing coverage. And while many Arkansas Medicaid beneficiaries are working, only a tiny percentage of those subject to the requirements — 0.5 percent in the latest monthly report — have newly reported work hours in response to the work reporting requirement. And even many of those beneficiaries might have found jobs without the new policy or might have already been working.[3] 

    In the recent Stewart v. Azar decision, which vacated approval of Kentucky’s waiver proposal to take coverage away from parents and other adults who don’t meet a work reporting requirement, the court found that a “central objective” of Medicaid is to provide coverage to poor and low-income people.[4] Tennessee’s proposal would take coverage away from poor parents even though the State is required to cover these parents under federal Medicaid law, and, like Kentucky’s proposal, fails to promote Medicaid’s central objective of providing affordable coverage to those who would otherwise be uninsured.[5]


    While United Way supports work as a core value, we are opposed to any proposal that would take health coverage away from people who do not report working a set number of hours per month. As we’ve seen in other states that have already implemented such policies, the proposal will deprive eligible individuals of health coverage due to their inability, or the state’s inability, to document their compliance with complex new administrative requirements. This proposal would cause immense harm and jeopardize coverage for potentially tens of thousands of Tennesseans.

    We urge you to reject Tennessee’s proposal as it will lead to loss of coverage for thousands of parents in poverty. By taking coverage away from parents in poverty, the state’s proposal is incompatible with a central objective of the Medicaid program—to make coverage available to very low-income parents whom the state must cover under federal Medicaid law. 


    Mary B. Sellers

    U.S. President

    United Way Worldwide

    Alexandria, Virginia



    [1] U.S. District Court for the District of Columbia, Stewart v. Azar,

    [2] MACPAC, “The Role of Medicaid in Supporting Employment”, July 2018,

    [3] Jennifer Wagner, “Commentary; As Predicted, Arkansas’ Medicaid Waiver Is Taking Coverage Away From Eligible People,” Center on Budget and Policy Priorities, December 18, 2018,

    [4] Jennifer Wagner, “Medicaid Coverage Losses Mounting in Arkansas From Work reporting requirement,” Center on Budget and Policy Priorities, January 17, 2019,

    [5] Joan Alker and Olivia Pham, “Work Reporting Requirement for Tennessee Parents Would Harm Low-Income Families With Children,” Georgetown Center for Children and Families, January 30, 2019, To estimate this number, Georgetown researchers used analogous assumptions as were used to find Arkansas’s coverage loss ratio of 23 percent. They used the number of parents (300,000) estimated to be in the affected parent category from the state’s fiscal note and subtracted 2 percent (6,000) who are over 65 and not included. They then applied the 23 percent coverage loss ratio from Arkansas and got 67,620. It is important to note that Arkansas also has many exemptions and that the 23 percent result includes those who are exempt in the denominator. Fiscal Note

    HB 1551 – SB 1728, Tennessee General Assembly Fiscal Review Committee, February 12, 2018, available at Bills/110/Fiscal/HB1551.pdf.

    [6] Judith Solomon, “Medicaid Work reporting requirements Can’t Be Fixed,” Center on Budget and Policy Priorities, January 10, 2019,

    [7] Memorandum Opinion, Stewart v. Azar, Civil Action No. 1:18-cv-152 (JEB), District Court for the District of Columbia, June 29, 2018.

    [8] §1902(a)(10)(A)(i)(I) of the Social Security Act




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