Dear Honorable Members of the House Health and Human Services Committee:
On behalf of the more than 430 people with cystic fibrosis living in Iowa, the Cystic Fibrosis Foundation writes in opposition of HSB 248, which directs the state to implement community engagement and work requirements under the Iowa Health and Wellness Plan. We are committed to ensuring that the state’s Medicaid program provides critical healthcare coverage for those who qualify. Based on experience with similar policies in other states, we fear these requirements will lead thousands of people to lose coverage and jeopardize the healthcare of people with CF and other serious and chronic conditions.
About Cystic Fibrosis and the Cystic Fibrosis Foundation
Cystic fibrosis is a progressive, genetic disease that affects the lungs, pancreas, and other organs. There are close to 40,000 children and adults living with cystic fibrosis in the United States, and CF can affect people of every racial and ethnic group. CF causes the body to produce thick, sticky mucus that clogs the lungs and digestive system, which can lead to life-threatening infections. As a complex, multi-system condition, CF requires targeted, specialized treatment and medications. For those with CF, health care coverage is a necessity, and interruptions in care can lead to irreversible lung damage and costly hospitalizations — compromising the health and well-being of those with the disease. Over 60 percent of children and more than one in three adults living with CF in Iowa rely on Medicaid for some or all of their health care coverage.
As the world’s leader in the search for a cure for CF and an organization dedicated to ensuring access to high-quality, specialized CF care, the Cystic Fibrosis Foundation accredits more than 130 care centers nationally — including two in Iowa — that provide multidisciplinary, specialized care in accordance with clinical practice guidelines. As experts in CF care, the CF Foundation and our care centers understand the critical role of adequate, affordable health coverage, including through programs like Medicaid.
The Importance of Medicaid Expansion
The Medicaid expansion program plays an important role in helping patients afford the specialized care they need to stay healthy. Expanding Medicaid eligibility to childless adults with incomes up to 138 percent of FPL has allowed the state to extend coverage to nearly 180,000 additional individuals as of July 2024. For people with CF, adequate coverage is not a luxury but a necessity — ensuring access to critical, life-sustaining care and treatments. Consistent care and access to specialized therapies are necessary for people with cystic fibrosis, and any loss or gap in coverage — even for as little as one month — may put people with CF at risk of declining health. As CF is a progressive disease, delaying or forgoing daily therapies has serious implications, including increased risk of lung exacerbations, irreversible lung damage, and costly hospitalizations. The Medicaid expansion program has been crucial in ensuring people with CF can obtain adequate coverage, afford the care they need, and stay healthy enough to stay in the workforce.
Medicaid Work Requirements Jeopardize Access to Care
The Cystic Fibrosis Foundation strongly opposes work requirements as they threaten access to high-quality, specialized CF care for people with cystic fibrosis. Work requirements have been shown to result in widespread coverage losses, increased administrative burdens, and significant financial costs to the state — without achieving their intended goal of increasing employment. This policy contradicts the purpose of Medicaid by restricting coverage rather than expanding access to care, and we fear that people with CF who may lose coverage under this policy could see alarming declines in their health as a result.
While the Cystic Fibrosis Foundation appreciates the decision to exempt from work requirements individuals who are “medically certified as physically or medically unfit for employment,” we still have serious concerns about the administrative challenges someone with CF could face in understanding and navigating these requirements and the exemption process. Arkansas’ program is a prime example of how administrative burdens can jeopardize coverage. The November 2018 Arkansas Works program report shows an overwhelming majority — nearly 80% — of those required to log-in and report compliance with the work requirements or request an exemption failed to do so, putting these individuals at risk for loss of coverage. In total, 18,000 people in Arkansas lost Medicaid coverage as a result of the state’s work and community engagement requirements. Similarly, Georgia’s Pathways to Coverage Program, which includes work requirements, enrolled fewer than 5,000 individuals in its first year, instead of the projected 31,000-100,000 beneficiaries originally estimated to be eligible. This policy contradicts the goals of the Medicaid program and jeopardizes access to care for thousands of Iowans.
Moreover, work requirements impose significant financial costs on states. A similar proposal in Michigan was estimated to cost between $17.5 million and $70 million in administrative expenses. In Georgia, over $26 million have already been spent on implementing work requirements, with 90% allocated to administrative and consulting costs — funds that could be better used to provide quality, affordable healthcare. Taxpayer dollars should focus on providing quality, affordable healthcare coverage, not cutting it.
Ultimately, these requirements do not further the goals of the Medicaid program or help low-income individuals find work. Most people on Medicaid who can work already do so. According to the Kaiser Family Foundation, more than 90 % of adults with Medicaid coverage are either workers, caregivers, students, or unable to work due to illness. And continuous Medicaid coverage can actually help people find and sustain employment. In a report looking at the impact of Medicaid expansion in Ohio, the majority of enrollees reported that being enrolled in Medicaid made it easier to work or look for work (83.5% and 60%, respectively). That report also found that many enrollees were able to get treatment for previously untreated health conditions, which made finding work easier. Additionally, a study in The New England Journal of Medicine found that Arkansas’s work requirement was associated with a significant loss of Medicaid coverage, but no corresponding increase in employment. Terminating individuals’ Medicaid coverage for non-compliance with these requirements will hurt rather than help Iowans search for and obtain employment.
The Cystic Fibrosis Foundation urges you to oppose HSB 248, as this policy does not further the goals of the Medicaid program. We appreciate your attention to this important issue.