Medicaid work requirements built on invented evidence will harm the people they claim to help
The Centers for Medicare and Medicaid Services (CMS) has issued a new Interim Final Rule with comment period (IFC) implementing the Medicaid “community engagement” requirements included in H.R.
医疗保险和医疗补助服务中心 (CMS) 发布了新的暂行最终规则，并设有征求意见期 (IFC)，以实施 H.R. 中包含的医疗补助“社区参与”要求。
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The IFC is fundamentally defective in both its substance and its analysis.
国际金融公司在其实质内容和分析上都存在根本缺陷。
With respect to the analysis justifying the rule, the agency’s mandated Regulatory Impact Analysis (RIA) does not conform to the standards required of such analyses, as stipulated in Executive Order 12866 and the Office of Management and Budget (OMB) Circular A-4 .
关于证明该规则合理性的分析，该机构强制执行的监管影响分析 (RIA) 不符合第 12866 号行政命令和管理和预算办公室 (OMB) A-4 号通告中规定的此类分析所需的标准。
It substitutes unsupported assumptions for the best available empirical evidence, counts speculative benefits while omitting well-documented costs, and produces estimates of coverage loss and federal savings that are inconsistent.
它用没有支持的假设来代替现有的最佳经验证据，计算投机性收益，同时忽略有据可查的成本，并得出不一致的承保损失和联邦储蓄的估计。
With respect to the substance of the rule, CMS has added conditions, not required under the statute, that will make it even more difficult than the statute intended for people with mental illnesses and substance use disorders to retain coverage.
关于规则的实质内容，CMS 增加了法规中未要求的条件，这将使精神疾病和药物滥用障碍患者保留保险范围比法规更加困难。
These are not technical shortcomings.
这些并不是技术缺陷。
This rule will determine whether millions of low-income Americans retain health insurance.
这条规则将决定数百万低收入美国人是否保留医疗保险。
H.R.
H.R.
1 requires certain Medicaid beneficiaries to document 80 hours a month of work or other qualifying activities to retain their eligibility for Medicaid.
1 要求某些医疗补助受益人记录每月 80 小时的工作或其他合格活动，以保留其医疗补助资格。
This IFC sets forth the rules defining which beneficiaries will and will not be exempt from this “community engagement” requirement.
该国际金融公司制定了规则，定义哪些受益人将或不会免除这一“社区参与”要求。
Under Executive Order 12866 , economically significant regulatory actions, such as this IFC, must be accompanied by an RIA that assesses the costs and benefits of the action.
根据第 12866 号行政命令，具有经济意义的监管行动（例如本 IFC）必须附有评估该行动成本和收益的 RIA。
In this case, the key parameter that will drive the costs and benefits of the regulatory action is how many people will become employed or otherwise community-engaged under the threat of losing Medicaid coverage.
在这种情况下，决定监管行动成本和收益的关键参数是，在失去医疗补助覆盖范围的威胁下，有多少人将就业或以其他方式参与社区活动。
OMB requires agencies to base regulatory analyses on the best reasonably obtainable scientific, technical, and economic information.
OMB 要求各机构根据可合理获得的最佳科学、技术和经济信息进行监管分析。
CMS acknowledges that it does not estimate this key behavioral response parameter from any such information.
CMS 承认它不会根据任何此类信息估计这一关键行为反应参数。
Instead, it assigns subjective weights to hypothetical scenarios.
相反，它为假设场景分配主观权重。
In its assessments of costs and benefits, CMS simply assumes that roughly one-third of affected beneficiaries will move into qualifying activities because of the requirement.
在成本和收益评估中，CMS 简单地假设大约三分之一的受影响受益人将因这一要求而进入符合资格的活动。
That assumption is wildly out of line with a substantial body of empirical evidence.
这一假设与大量经验证据严重不一致。
Three distinct, robust lines of research, all consistent with one another, could have been used to estimate the likely impact of the requirement.
三个截然不同、稳健的研究方向彼此一致，可用于估计该要求可能产生的影响。
First, studies of welfare-to-work programs, which condition receipt of cash benefits on employment, generally find small employment effects, with effects of under 5% even in scenarios where the work requirements in the programs are accompanied by childcare, transportation assistance, case management, and other supports—no such supports are included in the Medicaid rule.
首先，对以就业为条件获得现金福利的福利转工作计划的研究通常发现就业影响很小，即使在计划中的工作要求伴随着儿童保育、交通援助、案件管理和其他支持的情况下，影响也低于 5%——医疗补助规则中不包括此类支持。
Second, studies of the Affordable Care Act’s Medicaid expansion—the converse of the new work requirements—find that gaining Medicaid has little or no effect on employment, implying that withdrawing coverage is unlikely to produce a substantial increase in engagement.
其次，对《平价医疗法案》医疗补助扩展（与新工作要求相反）的研究发现，获得医疗补助对就业影响很小或没有影响，这意味着取消保险不太可能大幅提高参与度。
Finally, studies of recent work requirements in the Supplemental Nutrition Assistance Program (SNAP) and Medicaid—including Arkansas’s Medicaid work requirements waiver—have found substantial coverage losses but no measurable increase in employment.
最后，对补充营养援助计划 (SNAP) 和医疗补助计划（包括阿肯色州医疗补助工作要求豁免）近期工作要求的研究发现，保险覆盖范围大幅下降，但就业率没有明显增加。
CMS’ assumption that one-third of those subject to the work requirement will become community-engaged is over six times greater than the largest estimate in any of these literatures.
CMS 的假设是，受工作要求约束的人中有三分之一将参与社区活动，这一假设比任何这些文献中最大估计值的六倍多。
That assumption is an invention from which the agency mechanically generates its estimates of employment, earnings, costs, benefits, and government savings.
该假设是一项发明，该机构可以根据该假设机械地生成对就业、收入、成本、福利和政府储蓄的估计。
Because those estimates carry through the entire analysis, they generate further inconsistencies and distortions.
由于这些估计贯穿了整个分析，因此会产生进一步的不一致和扭曲。
The one-third engagement estimate leads CMS to predict that only about 3.1 million to 3.3 million people will lose Medicaid coverage annually.
根据三分之一的参与度估计，CMS 预测每年只有约 310 万至 330 万人将失去医疗补助覆盖范围。
By contrast, the Congressional Budget Office (CBO) estimated that the statutory work requirement would reduce Medicaid enrollment by approximately 5.7 million people .
相比之下，国会预算办公室 (CBO) 估计，法定工作要求将使医疗补助参与人数减少约 570 万人。
Yet despite this much smaller headcount, CMS simultaneously projects approximately $350 billion in federal savings over 10 years—10% more than CBO’s estimate of $317 billion .
然而，尽管员工人数少得多，CMS 同时预计 10 年内联邦节省约 3,500 亿美元，比 CBO 估计的 3,170 亿美元高出 10%。
These figures are difficult to reconcile.
这些数字很难协调。
If CMS expects fewer people to lose coverage but more money to be saved, it must implicitly assume that those losing coverage are dramatically more expensive than the beneficiaries reflected in CBO’s calculation.
如果 CMS 预计失去保险的人更少，但可以节省更多的钱，那么它必须隐含地假设那些失去保险的人比 CBO 计算中反映的受益人要贵得多。
CMS’s numbers appear to imply average federal Medicaid spending of roughly $11,000 for each disenrolled person, compared with about $5,600 in CBO’s estimate.
CMS 的数据似乎意味着每个退出者的平均联邦医疗补助支出约为 11,000 美元，而 CBO 的估计约为 5,600 美元。
1 But Medicaid spending is highly concentrated.
1 但医疗补助支出高度集中。
Many of the most expensive beneficiaries have serious health conditions that should qualify them for exemptions or temporary hardship protections.
许多最昂贵的受益人有严重的健康状况，应该有资格获得豁免或临时困难保护。
CMS does not adequately explain how its relatively small group of projected disenrollees can generate such large savings.
CMS 没有充分解释其预计退出人数相对较少的群体如何能够产生如此大的节省。
The implausible engagement assumption shows up again in the agency’s claims about the IFC’s benefits.
令人难以置信的参与假设再次出现在该机构关于国际金融公司利益的声明中。
Here, the agency claims that those shifted to engagement through the work requirement will become healthier from being induced into employment.
该机构声称，那些通过工作要求转向参与的人将因被诱导就业而变得更健康。
The research basis CMS cites for the assumption that work makes you healthy is entirely based on associational studies of the health of workers and non-workers.
CMS 引用的“工作使人健康”这一假设的研究基础完全基于对工人和非工人健康的关联研究。
Healthier people are more likely to work.
更健康的人更有可能工作。
Poor health makes it harder to obtain and retain employment.
健康状况不佳使得获得和保留就业变得更加困难。
Education, family resources, housing stability, and other factors affect both employment and health.
教育、家庭资源、住房稳定性等因素影响就业和健康。
Studies showing that employed people are healthier than unemployed people in no way establish that requiring a Medicaid beneficiary to work will make that person healthier.
研究表明，就业者比失业者更健康，但这绝不表明要求医疗补助受益人工作就会使该人更健康。
Indeed, the limited causal research, which relies on changes in retirement rules and other sources of plausibly exogenous variation, has produced mixed results : some studies find benefits from continued work, while others find that working harms health (for example, by increasing the risk of workplace injuries).
事实上，有限的因果研究依赖于退休规则的变化和其他看似合理的外生变异来源，产生了好坏参半的结果：一些研究发现继续工作有好处，而另一些研究则发现工作有害健康（例如，增加工作场所受伤的风险）。
There is no credible basis for assigning large health benefits to the hypothetical employment increases assumed to be generated by this rule.
没有可靠的依据将大量健康福利分配给该规则假定的假设就业增长。
At the same time, CMS largely omits the strongest causal evidence in this area: Medicaid coverage improves access to care, financial security, and health.
与此同时，CMS 很大程度上忽略了这一领域最强有力的因果证据：医疗补助覆盖范围改善了获得护理、财务安全和健康的机会。
Randomized and quasi-experimental studies have linked insurance coverage to improved treatment and, in several very credible studies , lower mortality.
随机和准实验研究将保险覆盖范围与改善治疗联系起来，并且在几项非常可信的研究中，还与降低死亡率联系起来。
Other research shows that, at least for some populations, access to effective treatment can improve employment.
其他研究表明，至少对于某些人群来说，获得有效治疗可以改善就业。
Randomized studies of depression care , for example, have found increases in job retention, hours worked, and employment.
例如，抑郁症护理的随机研究发现，工作保留率、工作时间和就业率都有所增加。
In other words, health coverage keeps people healthy and may help people work.
换句话说，健康保险可以保持人们的健康，并可以帮助人们工作。
Taking coverage away has direct harms and may make employment less likely.
取消保险会带来直接危害，并可能降低就业机会。
CMS’s analysis largely reverses this relationship: it assumes that work produces health while ignoring the possibility that health care produces both work and health.
CMS 的分析在很大程度上扭转了这种关系：它假设工作产生健康，而忽略医疗保健同时产生工作和健康的可能性。
The rule is especially poorly designed for people with mental illnesses and substance use disorders.
该规则对于患有精神疾病和药物滥用障碍的人来说尤其糟糕。
In the original statute, Congress provided exemptions for people with qualifying behavioral health conditions.
在最初的法规中，国会为具有合格行为健康状况的人提供了豁免。
CMS, however, would require many individuals to demonstrate not merely that they have a qualifying diagnosis, but that the condition significantly impairs their ability to comply with the work requirement.
然而，CMS 要求许多人不仅证明他们有合格的诊断，而且证明这种情况严重损害了他们遵守工作要求的能力。
Standard administrative reporting, such as medical claims, does not contain information on functional ability.
标准行政报告（例如医疗索赔）不包含有关功能的信息。
That means that meeting the exemption will require a new miniature disability determination.
这意味着要满足豁免要求，需要进行新的小型残疾认定。
States and clinicians will have to assess functional capacity, collect documentation, and decide whether a particular condition prevents compliance with 80 hours of monthly activities.
各州和临床医生必须评估功能能力、收集文件并决定特定情况是否妨碍遵守每月 80 小时的活动。
States conduct such capacity determinations in conjunction with Social Security disability determinations; a costly, challenging process that provides applicants with important procedural protections (but nonetheless makes consequential errors).
各国将此类能力确定与社会保障残疾确定结合起来；这是一个成本高昂且具有挑战性的过程，为申请人提供了重要的程序保护（但仍然会出现严重错误）。
Requiring such functional status determinations for people with mental illnesses and substance use disorders is particularly damaging because these conditions can impair memory, concentration, planning, and motivation.
对患有精神疾病和药物滥用障碍的人进行此类功能状态测定尤其具有破坏性，因为这些情况会损害记忆、注意力、计划和动机。
People with these conditions are likely to find it particularly difficult to navigate bureaucratic systems.
具有这些条件的人可能会发现在官僚系统中驾驭特别困难。
The people most impaired may be those least able to prove that impairment.
受损最严重的人可能是最无力证明这种受损的人。
The functional status criteria also fail to account for the fact that behavioral health conditions are chronic and recurring.
功能状态标准也未能考虑到行为健康状况是慢性且反复出现的事实。
A person with opioid use disorder, schizophrenia, bipolar disorder, or recurrent major depression may be stable enough to work for one month, experience a relapse the next, miss a reporting deadline, and lose the Medicaid coverage financing the treatment that helped maintain stability and employment.
患有阿片类药物使用障碍、精神分裂症、双相情感障碍或复发性重度抑郁症的人可能足够稳定，可以工作一个月，但下个月就会复发，错过报告截止日期，并失去为帮助维持稳定和就业的治疗提供资金的医疗补助覆盖范围。
Current functioning while under treatment is not proof that an exemption is unnecessary.
治疗期间目前的功能并不能证明不需要豁免。
It may instead be evidence that treatment is working.
相反，这可能是治疗有效的证据。
The statute particularly called for an exemption for those participating in substance use treatment programs.
该法规特别要求对那些参与药物使用治疗计划的人给予豁免。
The CMS rule places very restrictive conditions on what participation means.
CMS 规则对参与的含义设置了非常严格的条件。
In particular, it limits the exemption to care provided by nonprofit providers.
特别是，它限制了对非营利提供者提供的护理的豁免。
However, nearly half of people receiving substance use treatment are served by for-profit organizations, and the share is particularly high among opioid treatment programs providing methadone.
然而，近一半接受药物滥用治疗的人是由营利性组织提供服务的，在提供美沙酮的阿片类药物治疗计划中这一比例尤其高。
That means that patients receiving substance abuse treatment could lose exemption from work requirements because the providers who happen to be available in their communities are for-profit.
这意味着接受药物滥用治疗的患者可能会失去工作要求的豁免，因为恰好在其社区提供服务的提供者是营利性的。
That will be particularly damaging in rural areas and other places with thin treatment networks.
这对于农村地区和其他治疗网络薄弱的地方尤其具有破坏性。
The IFC is defective in its substance and its design.
国际金融公司的实质和设计都有缺陷。
A defensible Regulatory Impact Analysis would use the following information:
合理的监管影响分析将使用以下信息：
Instead, CMS’s analysis assumes away the central empirical question, inflates speculative benefits, omits documented harms, and then adds administrative barriers that are likely to exclude precisely the people Congress intended to protect.
相反，CMS 的分析假设了核心的实证问题，夸大了投机性收益，忽略了有记录的危害，然后增加了行政障碍，这些障碍可能恰恰排除了国会想要保护的人民。