Like many other Oklahomans who have a criminal conviction, Lena Chatmon has struggled to rebuild her life since pleading guilty to motor vehicle-related and larceny charges in 2017.
Chatmon, 21, who lives in Tulsa, is unemployed and said many employers are reluctant to hire her because of her criminal record.
But as she continues to look for a job while on probation, she faces a new worry: the risk of losing her health insurance if a state proposal is approved that requires many Medicaid recipients to work at least 20 hours a week.
"I go to the doctor almost every month, and if I can't meet the 20 hours, I don't know what I would do," she said. "If that happens, I might have to neglect my health needs just so I don't go into debt."
Thousands of Oklahomans could find themselves in Chatmon's situation if the federal government accepts Oklahoma's request to link a work requirement to eligibility for SoonerCare, the state's Medicaid program.
Former Gov. Mary Fallin and the Legislature requested the rule last year in an effort to reduce Medicaid costs and ensure the program is serving only those who need it the most.
The waiver application, which the Trump administration could accept or reject this year, does allow exemptions for recipients who are younger than 19, pregnant, students, medically unable to work or are a parent or caretaker for a child younger than 6.
The proposal also includes a nine-month grace period starting when a felon is released from incarceration. But there are no exemptions for others.
The Medicaid rule alarms criminal justice reform advocates, who say the work requirement would jeopardize ex-felons' health and their ability to find and perform work. Historically, ex-convicts have suffered from high unemployment rates, poverty and physical and mental illness.
"The (work requirement) fails to recognize the stigma, discrimination and related legal and policy barriers to employment confronting people with criminal records," a coalition of health care and civil rights groups wrote in a letter last year when the Trump administration announced guidance for states to seek the waiver. "(It) will make it even more difficult for people with criminal records to obtain needed physical and mental health care services and medications critical to successful reentry."
The state Health Care Authority estimates that of the 102,000 SoonerCare recipients between ages 19 and 50, about 6,000 would not be covered by any exemptions if the work requirement takes effect next year.
A report from the Georgetown University Health Policy Institute puts the number higher, stating between about 4,400 and 12,600 would lose coverage and the number "would grow over time," especially in rural areas. Even many of those exempt from the work rule could lose coverage by failing to file documentation proving compliance, the report says. The report found the work requirement would affect low-income mothers most of all, as 80 percent of people subject to the rule would be women with children.
Dolores Verbonitz, a program manager for the Community Service Council's Tulsa Reentry One-Stop program, said this is a concern because Oklahoma leads the nation in incarceration rates among women.
She said her group routinely works with women who have children and depend on Medicaid. In many cases, they have children who are 6 or older, which would make the parent ineligible for a work-rule exemption.
Verbonitz said losing Medicaid could trigger other problems for those with criminal records, including less or no help with addiction or mental-health issues and more extreme poverty. Many employers of low-income workers don't offer affordable health insurance. With less help, many women could re-offend and end up back in prison.
"If you're not getting your basic health needs met, we can't even put them in job training programs," Verbonitz said. "We would just be setting them up for failure."
Data on the impact of the work requirement in other states is just starting to trickle in.
Since last year, the federal government has approved the work rules for only six states: Arkansas, Indiana, Kentucky, Michigan, New Hampshire and Wisconsin.
In Arkansas, the first to implement the new rules, more than 18,000 people were kicked off Medicaid between September and December because of the work requirement, according to a Kaiser Family Foundation report.
But like the five other states, Arkansas has at least partially expanded Medicaid to cover thousands of low-income adults who otherwise make too much to qualify for the program.
The Georgetown report noted that because Oklahoma hasn't expanded Medicaid, the work requirement would affect only those with incomes at or below 45 percent of the federal poverty level, meaning they earn less than $4,156 a year. If its waiver is approved, Oklahoma will become the first non-expansion state to add the work rule.
Pros and cons
More than 800 groups or individuals submitted public comments on the state's waiver application. A large majority opposed the work requirement, saying it would make Oklahomans less healthy.
But state officials say the opposite is true.
The Health Care Authority's waiver application contends that by disincentivizing unemployment, "Oklahoma could impact employment rates and improve health outcomes." It said the correlation between the two is well-established.
Republican lawmakers, who passed a bill directing Fallin to seek the Medicaid waiver, have said the proposal is needed from an economic standpoint.
"We must break the cycle of government dependence that is getting worse with each generation," Sen. Paul Rosino, R-Oklahoma City, said in a statement when the legislation passed last session. "I will continue to advocate for and support any legislation that helps strengthen Oklahoma families and our economy by helping more people become independent and self-sufficient."
Proponents say they were careful to exempt groups of people who can't work.
Health Care Authority spokeswoman Katelynn Burns said the agency held several public meetings last year to hear feedback on who should be excluded from the rule.
In the end, the agency decided that the nine-month grace period for ex-felons just released from incarceration would allow enough time to find employment. (Offenders with a suspended sentence would be excluded.)
John Pearson, who leads the Oklahoma Partnership for Successful Reentry, said the grace period wouldn't likely help the many ex-felons who rely long-term on sporadic work; they would have trouble meeting the 20-hours-per-week requirement.
Various studies have found that one year after release from prison, as many as 60 to 75 percent of former inmates remain unemployed.
"If they got a job by then, they are very fortunate. If they are sick, it is hard to get a job," Pearson said. "And if you don't have a job, you can't get healthy."
Pearson called the proposal a "travesty," saying the rule could at least erode Oklahoma's criminal justice reforms that seek to lower the state's chronically high incarceration rates.
"Oklahoma is never going to get off the bottom of the list this way," he said. "Otherwise we are just running a revolving door."