Comment on CMS-2026-2047-0002

To the Centers for Medicare and Medicaid Services: As a nonpartisan foundation focused on health care access, we are concerned that the Interim Final Rule (IFR) will have an adverse impact on adults who depend on Medicaid for their health insurance. We would like to call your attention to two groups that are at risk: caregivers of older adults and people with serious medical conditions. Caregivers of Older Adults In the United States, caregiving contributes to better health outcomes for care recipients, and, according to the AARP, family caregivers nationwide provide uncompensated labor estimated at an annual economic value of more than one trillion dollars. As the IFR is currently written, “caregiver” is narrowly defined and does not explicitly include caregivers of seniors, many of whom are themselves age 50 or older. The IFR allows an exemption for adults who care for dependents under age 14 and people with a disability. We interpret this to mean that in order for a caregiver of an older person to be exempt, the care recipient must have a qualifying disability. In other words, a 59-year-old man who spends a significant amount of his time caring for his 88-year-old father would not be exempt unless his father had a qualifying disability, such as blindness. Being of an advanced age is not enough—even though the son spends considerable time and attention taking care of his father’s physical, emotional, and practical needs. We request that states be allowed to use the broad definition of “caregiver” from the 2018 RAISE Act so that caregivers of older adults can be fairly considered for an exemption. Individuals with Chronic Medical Conditions We are also deeply concerned by the IFR’s narrow definition of “medically frail.” It has grave implications for people who suffer from serious or medical conditions such as cancer, end-stage renal disease, mental illness, and HIV. These individuals would qualify for an exemption only if their condition prevented them from working. The reality is that for those with chronic conditions, the ability to work often fluctuates. Some days—indeed, some weeks—are better than others. It all depends on a person’s physical and emotional strength in response to life circumstances that may include ongoing treatment. Take the case of a patient with stage 2 cancer. While outpatient treatment might be going well, there may be periods when the person’s side effects from treatment may be severe enough to limit their ability to attend work or school. Any gap in a qualifying activity could result in loss of Medicaid coverage, jeopardizing the person’s access to care. Losing their health insurance would make it harder for them to continue treatment, which could cause their medical condition to worsen. Providers would have another administrative burden to add to the new reporting obligations: documenting each instance in which their patient was incapable of completing a qualifying community engagement activity. We request that states be allowed to use their own judgment to determine short-term hardship exemptions. Finally, according to KFF, a nonpartisan organization focused on health policy research, data from the 2023 Current Population Survey and 2022 Survey of Income and Program Participation indicate that the majority of adults covered by Medicaid are either already working or are unable to work. Additionally, based on the assessment of the nonpartisan Congressional Budget Office, the new work requirements will not meaningfully increase employment among adults in the Medicaid program. We respectfully ask you to reconsider the efficacy of the proposed changes set to take effect on January 1, 2027. We believe they will do much more harm than good. Thank you for the opportunity to share our perspective. The Health Foundation for Western & Central New York