MARY LOUISE KELLY, HOST:
As Republicans push Medicaid reform, many have said they want to eliminate waste, fraud and abuse. Here's Senate Majority Leader John Thune on one main target.
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JOHN THUNE: Able-bodied adults who can work but refuse to work.
KELLY: Well, Katheryn Houghton, with our partner KFF Health News, has the story of a man who said he had to break Medicaid's rules.
JAMES: Just another day in paradise.
KATHERYN HOUGHTON: In a hot parking lot in Missoula, Montana, after an eight-hour shift, James sinks into his car and coaxes it to start.
JAMES: Yeah, so no AC yet (laughter).
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HOUGHTON: James is in his late 30s. He makes sandwiches for about $16 an hour, and that's with a recent raise.
JAMES: Well, you know, it also means that on the books, that's just more money.
HOUGHTON: More than his roughly $21,000-a-year income limit to qualify for Medicaid. We're using his middle name because James fears losing his health coverage. Right now, he's over the income limit by about 50 bucks a week. Still, he can't afford his medicine or to rent a house with his girlfriend. James finishes a post-work cigarette outside a relative's house, where he's staying for cheap.
JAMES: It certainly feels like progress is punishable. If you stay in the mud, they'll throw you a bone.
HOUGHTON: Recently out of addiction treatment, James finally has a mix of medicine that curbs his desire for alcohol and eases his chronic conditions, like insomnia. When he got kicked off Medicaid, he found the cheapest health plan he qualifies for doesn't pay for the prescriptions that let him sleep at night.
JAMES: I only saw one option - fudge the numbers.
HOUGHTON: So this problem - getting just successful enough to risk losing Medicaid - it's common. It has a name, a benefit cliff. Pamela Herd researches obstacles around government aid at the University of Michigan.
PAMELA HERD: It just doesn't make any sense that someone gets a dollar pay raise and all of a sudden, they lose all access to their health insurance.
HOUGHTON: She says there's a partial fix - continuous eligibility. Once people qualify for Medicaid, guarantee that access for at least a year. The idea is to give people time to figure things out when they do earn more money. But Congress is going the other way - shorter windows of coverage and frequent eligibility checks, all to save money on Medicaid. Herd says that will put more people on the benefit cliff.
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HOUGHTON: That's especially hard for those with chronic conditions, like James in Montana, who takes 12 pills a day.
JAMES: Trazodone, this is a lifesaver. So within 45 minutes, I am out.
HOUGHTON: James is lying in order to get those pills, but policy people say that's not the norm. Most don't know the system well enough to skirt the rules. Research shows millions of Americans don't use Medicaid when eligible. The system's confusing. Hiding hours at work bothers James, but not enough to give up his medicine.
JAMES: So now, every time I get a piece of mail, I am terrified that I'm going to open it up, and it's going to say I don't have Medicaid anymore. Yeah, I'm constantly in fear that it's going to go away.
HOUGHTON: Despite that fear, things are good right now. He's going to school part-time to become a counselor. In a few years, he could help others survive addiction.
JAMES: That would be really cool (laughter).
HOUGHTON: But to him, all this progress hinges on keeping Medicaid a little bit longer.
JAMES: I don't want to be a fraud, but I've been given no other choice.
HOUGHTON: Policymakers might disagree.
I'm Katheryn Houghton in Missoula.
KELLY: And Katheryn is with our partner KFF Health News. Transcript provided by NPR, Copyright NPR.
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