Erica Carter of Sioux City, Iowa, says she enjoys her job as a finance manager for the Omaha Nation public school district in Nebraska, working to find grants and opportunities for low-income students. But when she learned her pay was too high for her to remain in an Iowa Medicaid program, Carter had to choose — leave the job or give up her benefits.
Natalie Krebs/Iowa Public Radio
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Erica Carter is passionate about her job, and she has 7 acres of flowers and vegetables to show for it.
Carter's specialty is reeling in grants to support students in the Omaha Nation school district, where she is a finance manager. One paid for the garden that sits next to the district's campus. Another allowed the school system, in one of Nebraska's lowest-income counties, to pay students to maintain it.
This story was produced in partnership with KFF Health News.
"They're out in the sun. They're watering plants," she said. "It's the first time they get a paycheck in their life."
Carter, 41, is paralyzed from the chest down, an injury she's lived with since a fall in her early 20s. It didn't slow her down as she built her accounting career and got a master's degree in human resource management.
But in November 2023, Carter — who lives in Sioux City, Iowa — got a letter from Iowa's Department of Health and Human Services. It said that her income was too high for her to stay on Medicaid and that she might lose her benefits in two weeks if she didn't take action.
States are scrambling to get ready for a new federal requirement to double-check that many people on Medicaid qualify for the benefit, by showing they are working, volunteering, or studying at least 80 hours per month. Politicians' focus on requiring work has angered many people with disabilities who have Medicaid and say current policies that apply to them have the opposite effect — making them choose between working or receiving benefits.
When Carter got the letter, she was making $110,000 a year, well above Iowa's 2023 income limit for working people with disabilities: $36,450 for a household of one.
"I had no time at all to prepare," she said. "I had a decision to make."
At the time, Carter got her health coverage through Iowa's Medicaid for Employed People With Disabilities, a "buy in" program that allows working disabled Iowans to pay a part of their income to the state to maintain access to Medicaid benefits. Forty-seven states offer Medicaid buy-in programs, but most restrict eligibility through limits on income and assets.
For years, disability rights advocates have pushed state legislatures to change the limits, arguing that they prevent people like Carter from accepting raises or building savings, for fear of losing crucial medical benefits. Massachusetts, Minnesota, New Jersey and Rhode Island have eliminated such limits over the past five years.
To keep her Medicaid coverage, Carter would've had to find a job paying her far less than she was making. Or she could drop her Medicaid coverage and enroll in the school district's health plan. But that plan didn't cover many of the disability-related expenses that Medicaid did.
Carter decided to keep her job and leave the Medicaid buy-in program. In the end, the decision felt like a no-brainer, she said.
"I like getting up and going to work every day, and I really like what I do," she said. "Why would I throw that away?"