By Javar Juarez (CUBNSC) Columbia, S.C. - Governor Henry McMaster’s recent press release regarding the Healthy Connections Community Engagement Initiative has sparked intense debate across South Carolina. In his statement, the governor claimed that the initiative was intended to close healthcare gaps created by the Affordable Care Act (ACA) and incentivize employment among state residents. However, a closer analysis of this initiative and its implications reveals a troubling narrative, particularly for low-income families and marginalized communities.
Governor McMaster's Statement and Its Implications
Governor McMaster stated:
"South Carolina pursued the Section 1115 waivers that made up its Healthy Connections Community Engagement Initiative to close the health care coverage gap created by the Patient Protection and Affordable Care Act (ACA) and incentivize employment among its citizens. Under the ACA, adults are eligible for subsidized health care coverage on the federal exchange when their earnings reach the federal poverty level. However, Medicaid coverage ends for many working parents at a threshold that is below the federal poverty level. This flawed structure created a health care coverage gap that disincentivizes many low-income families from earning additional income. This presents working families with an undesirable choice: earn additional income to support their family or lose their healthcare coverage."
While this statement superficially frames the initiative as a solution to healthcare disparities, it obfuscates the real impact of policies targeting Medicaid recipients, particularly in low-income and BIPOC communities.
The True Impact on Marginalized Communities
Medicaid plays a critical role in providing healthcare to low-income individuals, covering children, pregnant women, adults, people with disabilities, and older adults. In South Carolina, 37.3% of Medicaid recipients at birth between 2021 and 2023 were white, but Medicaid disproportionately serves higher percentages of Black, Hispanic, and Indigenous populations. These groups are more likely to face systemic barriers to employment, transportation, and healthcare access, compounding the challenges of meeting strict eligibility requirements.
African American communities, in particular, stand at a precipice. The state’s stagnant minimum wage of $7.25—unchanged since 2008—falls far below the $18.99 per hour living wage estimated by the MIT Living Wage Calculator. Coupled with a lack of affordable childcare and transportation, many families face insurmountable obstacles in securing employment that meets the state’s proposed community engagement requirements.
CMS Intervention and Criticism of the Initiative
The U.S. Centers for Medicare & Medicaid Services (CMS) has scrutinized South Carolina’s approach to the Healthy Connections Works demonstration, expressing serious concerns about its community engagement requirement. Key points include:
COVID-19 Challenges: CMS identified that the pandemic exacerbated existing economic and healthcare disparities, rendering community engagement requirements infeasible.
Coverage Loss Risk: CMS estimated that 7,100 individuals would lose Medicaid coverage in the program’s first year due to non-compliance or administrative barriers.
Administrative Failures: The state failed to address critical issues such as childcare shortages, transportation barriers, and economic hardships, which disproportionately impact low-income communities.
As a result, CMS withdrew its approval of the initiative in December 2021, concluding that it would not promote Medicaid’s statutory objectives.
A Disproportionate Burden on Vulnerable Populations
Data reveals that the initiative would disproportionately affect Black residents, mothers, and rural communities. Of those subject to the proposed requirements:
51% are Black (compared to 28% of South Carolina’s overall population).
86% are mothers, many of whom already face systemic employment barriers.
Research consistently shows that most Medicaid recipients are already working or are exempt due to caregiving responsibilities or disabilities. Imposing additional administrative hurdles risks disenrolling beneficiaries not because they fail to meet requirements, but because of confusion, lack of awareness, or bureaucratic inefficiencies.
The Broader Consequences
The governor’s initiative underscores a broader trend of conservative policies targeting “entitlement” programs under the guise of promoting self-sufficiency. However, these measures often result in significant harm, including:
Increased Medical Debt: Loss of Medicaid coverage forces families to delay or avoid necessary care, leading to worsening health outcomes and higher medical bills.
Widening Inequities: BIPOC communities, already disproportionately affected by poverty and unemployment, bear the brunt of these policies.
Unrealized Employment Goals: Evidence suggests that such requirements have minimal impact on increasing employment rates, as most Medicaid recipients are already employed or face barriers beyond their control.
Governor McMaster’s Healthy Connections Community Engagement Initiative is emblematic of policies that disproportionately harm vulnerable populations under the guise of reform. As the state grapples with rising healthcare disparities, stagnant wages, and systemic inequities, it is imperative to focus on solutions that expand access to care rather than erect barriers.
South Carolina’s policymakers must counter these regressive measures with initiatives that prioritize healthcare equity, economic opportunity, and support for marginalized communities. The time to act is now—before more South Carolinians are pushed to the brink of losing access to the healthcare they need and deserve.
Reference:
U.S. Centers for Medicare & Medicaid Services. South Carolina Healthy Connections Works State Letter. 10 Aug. 2021, https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/sc-healthy-connections-works-state-ltr-08102021.pdf. Accessed 22 Jan. 2025.
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