Rewriting the rules on health care for the poor, the Trump administration said Thursday it will allow states, including Wisconsin under Gov. Scott Walker, to require “able-bodied” Medicaid recipients to work, a hotly debated first in the program’s half-century history.
Seema Verma, head of the Centers for Medicare and Medicaid Services, said requiring work or community involvement can make a positive difference in people’s lives and in their health. The goal is to help people move from public assistance into jobs that provide health insurance.
“We see people moving off of Medicaid as a good outcome,” she said.
But advocates said work requirements will become one more hoop for low-income people to jump through, and many could be denied needed coverage because of technicalities and challenging new paperwork. Lawsuits are expected as individual states roll out work requirements.
“All of this on paper may sound reasonable, but if you think about the people who are affected, you can see people will fall through the cracks,” said Judy Solomon of the Center on Budget and Policy Priorities, which advocates for the poor.
Created in 1965 for families on welfare and low-income seniors, Medicaid now covers more than 70 million people, or about 1 in 5 Americans. The federal-state collaboration has become the nation’s largest health insurance program.
Beneficiaries range from pregnant women and newborns to elderly nursing home residents. Medicaid was expanded under former President Barack Obama with an option allowing states to cover millions more low-income adults. Many of them have jobs that don’t provide health insurance.
People are not legally required to hold a job to be on Medicaid, but states traditionally can seek federal waivers to test new ideas for the program.
In Wisconsin, Walker also wants to require able-bodied, childless adults applying for Medicaid to undergo drug screening.
Verma stressed that the administration is providing an option for states to require work, not making it mandatory across the country. Her agency spelled out safeguards that states should put in place to get federal approval for their waivers.
States can also require alternatives to work, including volunteering, caregiving, education, job training and even treatment for a substance abuse problem.
Nine other states in addition to Wisconsin have applied for waivers involving work requirements or community involvement, the administration said. They are: Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina and Utah. Advocates for low-income people say they expect Kentucky’s waiver to be approved shortly.
In Kentucky, which expanded Medicaid, Republican state Sen. Damon Thayer said work requirements could lessen the program’s impact on the state budget. They also hearken back to the program’s original intent, he added, “as temporary assistance to try to help people get back on their feet, not a permanent subsidy for someone’s lifestyle, if they’re capable of working.”
But congressional Democrats said the Trump administration is moving in the wrong direction.
“Health care is a right that shouldn’t be contingent on the ideological agendas of politicians,” said Sen. Ron Wyden of Oregon, the top Democrat on the Senate committee that oversees Medicaid.
The debate about work requirements doesn’t break neatly along liberal-conservative lines.
A poll last year from the nonpartisan Kaiser Family Foundation found that 70 percent of the public supported allowing states to require Medicaid recipients to work, even as most Americans opposed deep Medicaid cuts sought by congressional Republicans and the Trump administration.
Another Kaiser study found that most working-age adults on Medicaid are already employed. Nearly 60 percent work either full time or part time, mainly for employers that don’t offer health insurance.
Most who are not working report reasons such as illness, caring for a family member or going to school. Some Medicaid recipients say the coverage has enabled them to get healthy enough to return to work.
Thursday’s administration guidance spells out safeguards that states should consider in seeking work requirements. These include:
The administration said states must fully comply with federal disability and civil rights laws to accommodate disabled people and prevent those who are medically frail from being denied coverage. States should try to align their Medicaid work requirements with similar conditions in other programs, such as food stamps and cash assistance.
The National Association of Medicaid Directors, a nonpartisan group representing state officials, said in a statement there’s no consensus on whether work requirements are the right approach.
“This is a very complex issue that will require thoughtful and nuanced approaches,” said the group.
Trump’s new direction can be reversed by a future administration. Although waivers can have lasting impact, they don’t amount to a permanent change in the program. They’re considered “demonstration programs” to test ideas. The administration says the impact will be closely evaluated.
“We know that Republicans tend to think of Medicaid more as a welfare program, while Democrats tend to think of it as more of a health insurance program,” said Diane Rowland, the Kaiser foundation’s leading expert on the program. “It will be interesting to see how states are going to make this work for people.”
The first thing a newcomer notices is the smell.
Inside this warehouse on the northern edge of Edgerton, the scent of unprocessed tobacco fills the air. It’s a thick but satisfying aroma, one much purer than that of cigarettes.
It’s a smell a newcomer would grow accustomed to if he spent his entire life harvesting tobacco as Tim Krausse has.
Krausse, 52, is one of a handful of farmers in the Edgerton area still harvesting tobacco. It’s a labor-intensive crop with a flat financial outlook, but he perseveres.
“You got to like it to do it. I enjoy it,” Krausse said. “I probably wouldn’t do it if I didn’t enjoy it. It’s got to be in your blood.”
Unlike most crops that are planted, grown and harvested, tobacco production lasts long after the plant leaves the soil. The time it spends in the ground is actually relatively brief—planted in June and harvested in late August or early September, Krausse said.
Then the stalks are hung inside a shed to cure, or dry, and remain there through the fall.
Thursday evening’s sudden freeze notwithstanding, this soggy week of mild weather is exactly what Krausse needs this time of year. Called “case weather,” the warm and damp conditions keep the air moist enough for workers to take down cured tobacco stalks and later strip them of their leaves.
The Krausses’ stripping strategy is different from most. Many tobacco farmers hang their cured stalks on a lath and strip the leaves at their own pace, said Tim’s son Kaleb Krausse.
But to get anything accomplished that way, the Krausses would need plenty of labor because using a lath is slow work. It would be expensive to hire enough people, and people interested in such arduous work are hard to find anyway, Kaleb said.
So instead, the Krausses use a conveyor and a small group of hired help to strip stalks. The stalks are fastened to one end of the overhead chain, and the leaves are then pulled off and stuffed into a temporary storage bin.
It’s best to grab the oily, leathery leaves where they meet the stalk and pull up. They come off easiest that way but still leave fingers blackened from their oil.
Edgerton was once a hub of tobacco production in Wisconsin. Drivers heading north on Highway 51 will see a Wisconsin Historical Marker at the southern edge of the city, touting the region as the state’s first home of commercial tobacco.
Edgerton still holds its annual Tobacco Heritage Days festival each July. But most of its cream brick warehouses have vanished, and the ones that remain are vacant or have been converted into other uses.
Bob Bartz, state manager for Viroqua Leaf Tobacco, said tobacco production has evaporated in his 45 years in the industry. He estimated Wisconsin produced only 1.2 million pounds of tobacco this past year.
His guess is probably accurate. Wisconsin produced 1.8 million pounds in 2012, the most recent year of available data. Aside from a few fleeting increases, production has steadily dwindled over the last several decades, according to U.S. Department of Agriculture data.
As recently as 1982, Wisconsin harvested more than 20 million pounds of tobacco annually. Even that is a far cry from a peak of 62.4 million pounds in 1918.
Kaleb mostly enjoys working outdoors during tobacco harvest season, but he acknowledges the historical connection to Edgerton’s legacy crop.
“That’s fun knowing that you still do something that they did how many years ago, and that’s what your town was built around,” Kaleb said. “It’s kind of nice doing that.”
The Krausses said tobacco prices have remained flat for years. At least corn and soybeans will have their occasional windfall years, but that doesn’t happen with tobacco, they said.
The Krausses dabble in many types of farming. They do corn, soybeans, beef, pork, custom planting and combining, and also haul grain through their trucking business.
Tobacco’s busy winter fits neatly into the corn and soybean offseason, and the crop is entwined with their life story, so they stick with the work, Tim said.
Bartz said demand has fallen, and many former tobacco farmers simply lost interest. The ones who continue to produce the crop are creatures of habit.
“They’ve done it year in and year out. It’s hard to give it up. Nobody out here is going to make $1 million raising tobacco,” Bartz said. “The guys who are doing it, they aren’t doing it to lose money or not make money. It’s just what they’re used to doing. It’s been more and more of a challenge every year.”
The final step for the Krausses is to bundle the stripped leaves before taking them to a processor in Stoughton.
They do that task differently, too. Instead of using a machine that mechanically compresses the leaves, they use an air pressure system. That’s the Southern method, Kaleb said.
Tim estimated they would get 25 bundles finished by the end of the day. But roughly six to seven acres’ worth of cured tobacco stalks wait inside a storage shed, he said.
As the remaining stalks move in and out of the warehouse, their enveloping smell will hang in the air for at least another month.
Imagine basing your company’s budget on its performance more than two years ago.
That’s the way it works for the state’s technical colleges.
Blackhawk Technical College is trying to make sure it gets as much “performance-based” funding as it can.
At a meeting in December, college President Tracy Pierner launched budget discussions for the 2018-19 school year with a presentation on “outcome-based” funding.
For the 2017-18 school year, the college lost out on more than $138,000 in state funding because the school’s results in categories such as job placement of graduates with jobs in their chosen fields and the number of dual credits high school students earn.
Here’s a catch: The statistics used to determine performance-based funding are based on a three-year rolling average that starts with the 2013-14 school year, almost three years before Pierner started.
Here’s another catch: The funding isn’t based on performance alone. For example, Blackhawk Tech met every requirement in the “collaboration” category but still received less money than other technical colleges of its size because of its enrollment numbers.
Despite those caveats, Pierner thinks it’s a good system.
Outcomes-based funding was developed as Act 20 in the state’s 2013-15 biennial budget. Starting with the 2014-15 school year, a percentage of state funding for technical colleges would be based on seven of nine performance criteria. The percentage of funding for performance-based measures would start at 10 percent and increase. Technical colleges now receive 30 percent of their funding based on performance measures.
Performance criteria include job placement, graduates in high-demand fields, programs with industry credentials, number of dual enrollment credits, workforce training, collaboration between technical colleges, services to people in special populations such as veterans, and adult education and advancement statistics.
Some of the highlights from Blackhawk Technical College include:
Based on the three-year rolling average, 79.9 percent of students were employed in the fields of their choice within six months of graduation. That puts Blackhawk third out the five similarly sized technical colleges and eighth out of all 16 technical colleges.
Funding impact: The school received $30,000 less than average for similar-sized schools.
Based on the three-year rolling average, 72.5 percent of students earned degrees in such fields. Blackhawk is second out of the five similarly sized technical colleges, and third out of all 16 technical colleges.
Funding impact: None. This was not one of the seven criteria Blackhawk used.
Over three years, Blackhawk had 2,663 students involved in such courses, and about 45 percent of them were successful. That put Blackhawk second out of the five similarly sized colleges and sixth out of all 16 colleges.
Funding impact: The school received about $13,000 more than average for similar-sized schools.
That places it first among the five smaller technical colleges and seventh out of all 16 colleges.
Funding impact: The school received $16,000 less than average for similar-sized schools.
For the 2018-19 school year, the performance-based funding system will change. Schools will be rated on all nine categories. A 10th standard, credit for prior learning, will be added.
Credit for prior learning allows people to earn credit for skills they’ve already developed.
Pierner thinks that performance based funding will “bottom out” in the 2018-19 school year and then begin ticking up, when changes made in the last two years begin to bear fruit.
The technical college has received nine economic develop grants in the past two years. Previously, the college might have received one a year.
Blackhawk staff have worked to recruit more high school students, and Janesville School District Superintendent Steve Pophal has also made it a priority.
“I think we’re go to see a substantial increase, especially with Steve on the job,” Pierner said.
Even though the college’s enrollment is a disadvantage when it comes to performance-based funding, Pierner thinks the system works.
“There’s enough of a carrot there to keep people motivated, but you’re not forever under-resourced,” Pierner said.
All of the measurements are good goals, he said.
“And frankly, we take these measurements seriously for two major reasons,” Pierner said. “One is the that the goals are right, and we do need to get better at job placement, at training for high demand jobs.”
The second reason?
“It’s good for the community, and it’s good for our students,” Pierner said.
Bipartisan negotiators hoping to resolve the standoff over so-called Dreamers brought their proposed immigration package to the White House on Thursday but were quickly rebuffed by President Donald Trump and GOP leaders, who advised them to broaden their group to include other lawmakers.
The swift rejection, during a meeting in the Oval Office, shows how difficult it will be for Congress to develop a legislative solution to protect some 700,000 young immigrants when Trump ends the Deferred Action for Childhood Arrivals program in March.
The White House also made clear it does not want to include as part of the deal the Dream Act, which would expand the existing program, according to Sen. Tom Cotton, R-Ark., who took part in the meeting. Instead, the administration is seeking to protect a narrower universe of young immigrants who already have temporary DACA protections.
“I think we still have a ways to go,” White House legislative director Marc Short told reporters on Capitol Hill. “We’re pleased the bipartisan members are talking.”
The meeting comes after a federal judge this week issued an injunction halting Trump’s plans to end DACA, providing the immigrants with temporary relief. The administration plans to appeal.
More than 1,000 DACA recipients daily will face deportation in March, advocates say. They are young immigrants who were brought to the United States illegally as children but have temporary permits under DACA to work, attend school or serve in the military.
Only one Democrat, Sen. Dick Durbin of Illinois—a leader of the bipartisan Senate group—was among the seven lawmakers at the noontime meeting. It included Sen. Lindsey Graham, R-S.C., another leader of the bipartisan group, and four other House and Senate lawmakers.
Cotton, who has emerged as one of the strongest proponents of White House plans to limit legal immigration, called the bipartisan senators’ proposal a “joke.”
“It’s not even a fig leaf. It’s a pine needle,” Cotton told reporters after the meeting.
When House Majority Leader Kevin McCarthy, R-Calif., told Trump that a separate group of congressional leaders was planning to continue its own discussions later Thursday, the president told them: “Go do that,” according to Cotton.
The Senate group’s proposal focused on four elements that had been agreed to during a meeting Trump convened with lawmakers earlier this week at the White House.
Their proposal centered on a deal that would offer Dream Act-like deportation protections for the young immigrants in exchange for border security measures and new limits on legal immigration through family unification visas and the diversity lottery.
Cotton said the border security measures were insufficient, though, and only included one year of funding for development of Trump’s proposed border wall, far short of the $18 billion the White House has requested from Congress. The proposal would have provided $1.6 billion for border security.
The group’s proposal also did not fully end family unification, also known as “chain migration,” and only delayed the ability of Dreamers to bring in some other family members, including their adult siblings.
Similarly, the diversity lottery was not eliminated, as some are seeking, but instead shifted its 50,000 annual visas to other immigrant groups, namely Salvadorans and others who must leave the country as Trump ends their under temporary protected status.
Republican leaders distanced themselves from the bipartisan group.
McCarthy’s group includes the four No. 2 leaders in the House and Senate, which includes Durbin, House Democratic Whip Steny Hoyer of Maryland and Sen. John Cornyn of Texas, the GOP Whip.
Cornyn told reporters any deal needs support from more than the six senators who comprised the bipartisan group.
“It’s not going to be done by just a sub group,” he said.
State • 2A, 6A
Feds look into prison incident
Federal prosecutors are investigating an incident in which guards at Lincoln Hills School for Boys allegedly stormed into a disruptive 16-year-old inmate’s cell, broke his arm, strip searched him, left him naked for hours and didn’t get him to a doctor for more than a week.
School sorry for slavery query
A Wauwatosa private school that asked fourth-graders to list three good reasons for slavery and three bad ones apologized to parents after the mother of a black student shared the assignment on Facebook, calling it offensive. In a letter to parents, Our Redeemer Lutheran School in Wauwatosa agreed the homework was offensive and said it “showed a lack of sensitivity.”
Nation/World • 6B
Mixed day for Walmart workers
Walmart confirmed Thursday that it is closing 10 percent of its Sam’s Club warehouse stores—a move that a union-backed group estimated could cost thousands of jobs—on the same day the company announced that it was boosting its starting salary for U.S. workers and handing out bonuses. The world’s largest private employer said it was closing 63 of its 660 Sam’s Clubs over the next few weeks, with some shut already.
Hopes of mudslide rescues dim
More than two full days after mudslides ravaged the coastal town of Montecito, California, the search for the missing became an increasingly desperate exercise Thursday, with growing doubts about whether anyone would be found alive. Seventeen people from ages 3 to 89 were confirmed dead, and eight others were unaccounted for.
Sports • 1B-3B
Five pressing tasks for Pettine
If new Green Bay Packers defensive coordinator Mike Pettine is to replicate what his predecessor Dom Capers achieved in his first seasons with the team—the Packers finished second in total defense in 2009—he has a lot of work to do. Much of it centers around the defensive secondary.