The Center for Community Solutions is reviewing Ohio’s Group VIII Work Requirement and Community Engagement 1115 Demonstration Waiver based upon three criteria – coverage, cost and health. This brief examines the waiver from a racial equity perspective.
A draft Group VIII Work Requirement and Community Engagement 1115 Demonstration Waiver recently released by the Ohio Department of Medicaid could lead to civil rights and racial bias complaints from residents of many Ohio cities. That’s because, while the proposal largely waives employment and community engagement requirements in 26 overwhelmingly white Ohio counties because of their high unemployment rates it fails to exempt other communities with unemployment rates equally high or higher. Most of these non-exempted Ohio communities have either majority or significant African-American populations. At the same time, communities with significant numbers of African-Americans typically suffer from higher rates of infant and maternal mortality, chronic diseases and have lower life expectancy.
While the proposal largely waives employment and community engagement requirements in 26 overwhelmingly white Ohio counties because of their high unemployment rates, it fails to exempt other communities with unemployment rates equally high or higher.
The Ohio Department of Medicaid (ODM) recently unveiled a waiver proposal to the Centers for Medicare and Medicaid Services (CMS) to implement new eligibility requirements for more than 700,000 Ohioans. The proposal would require these Medicaid beneficiaries to work and/or participate in a “community engagement activity” for a minimum of 20 hours per week, or, to qualify for an exemption. At the same time, the waiver proposal would exempt childless adults living in certain Ohio counties that are exempt from Supplemental Nutrition Assistance Program (SNAP) and Able-Bodied Adults Without Dependents (ABAWD) work requirements because of high unemployment rates. ODM explained that they exempted this group because they wanted to “mitigate confusion amongst beneficiaries, reduce the administrative burden, and comply with the CMS Guidance.” The result is that Group VIII Medicaid beneficiaries living in 26 Ohio counties are largely exempt from having to comply with the new eligibility requirements. On average, the population in those exempted counties is 95 percent white. Meanwhile, numerous Ohio communities have unemployment rates equally as high, or higher, as the 26 exempted counties, but residents outside of the selected counties are not entitled to the same work requirement and/or community engagement exemptions.
This disparate treatment is not the result of a federal policy, but rather of state policy limits on SNAP and potential Medicaid ABAWD work exemptions to entire counties, instead of on individual communities within counties that would otherwise meet federal exemption criteria. For example, Cuyahoga County’s overall unemployment rate doesn’t meet federal exemption requirements, but the cities of Cleveland, Euclid and Maple Heights would all individually meet the requirement because of their designations as surplus labor areas by the U.S. Department of Labor. These three communities are also cities with, according to U.S. Census data, majority African-American populations. A 2015 report from the Kirwan Institute for the Study of Race and Ethnicity at The Ohio State University found a clear history of zoning, land use, redlining, urban renewal and explicit racial discrimination that has resulted in Cuyahoga County being one of the most racially segregated counties in the United States. The impact of this continued segregation, and resulting economic disadvantage, is well studied and reflected in poor outcomes across a wide variety of health and social measures. The current Medicaid waiver proposal, and its narrow criteria for unemployment exemptions, doesn’t treat these high unemployment communities the same as largely white communities in other parts of Ohio. Nor does the policy account for the effect of past discriminatory practices that have fostered continued residential segregation. This could serve to reinforce, rather than alleviate, the discrimination that these communities and neighborhoods have faced.
Cuyahoga County’s overall unemployment rate doesn’t meet federal exemption requirements, but the cities of Cleveland, Euclid and Maple Heights would all individually meet the requirement because of their designations as surplus labor areas by the U.S. Department of Labor
The obvious solution would be to withdraw the proposed waiver, but that is likely not possible because its submission was mandated by the Ohio General Assembly. However, the Ohio Department of Medicaid could help to mitigate racial discriminatory effects of the waiver by exempting beneficiaries who live within smaller units of government that meet the U.S. Department of Agriculture’s definition of communities with high unemployment and/or lacking sufficient jobs, instead of only making a determination based upon whether or not the county as a whole meets the exemption test.
 Vital Signs, African American Health, Centers for Disease Control, July 3, 2017
 Adams, Athens, Belmont, Carroll, Columbiana, Coschocton, Gallia, Guernsey, Harrison, Highland, Huron, Jackson, Jefferson, Lawrence, Mahoning, Meigs, Monroe, Morgan, Muskingum, Noble, Ottawa, Perry, Pike, Scioto, Trumbull, and Washington counties are exempted.
John Corlett was interviewed by Vice News about this topic, watch the piece below beginning at 5:22.