The Trump administration plans to do something no other administration has done before — allow states to impose work requirements on Medicaid recipients.
In the coming months, the Trump administration could approve waivers allowing eight states to implement the work requirements: Arkansas, Arizona, Indiana, Kentucky, Maine, New Hampshire, Utah and Wisconsin. All but three of the states accepted ObamaCare’s expansion of Medicaid to cover more low-income adults.
The Obama administration rejected similar waiver requests, but “those days are over,” according to Seema Verma, the administrator of the Centers for Medicare & Medicaid Services (CMS).
Verma has said that arguments against the work requirements are “a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration.”
But the Trump administration’s move is almost certain to face litigation, with opponents arguing the requirements would undermine Medicaid’s mission of providing health care to low-income people.
“Not only will work requirements impede access to health-care coverage for individuals who aren't able to work, but they will also create difficult administrative hurdles for the vast majority of individuals on Medicaid who are already working,” said Catherine McKee, a senior attorney with the National Health Law Program (NHeLP).
The government has long allowed states to apply for waivers to certain Medicaid rules. But for a waiver to be approved, the states must show that the policies would support or promote the objective of extending coverage to the poor.
“Work requirements do not meet these standards,” McKee said.
“The purpose of Medicaid is to furnish medical assistance to low-income individuals. Work requirements reduce access to this assistance, which people need to be able to work.”
If the administration approves work requirements for Medicaid, McKee said, “NHeLP will certainly evaluate the possibility of a legal response.”
Proponents of the work requirements say they would give recipients more “skin in the game” and help states deal with the growing costs of Medicaid coverage.
Kentucky, for example, wants to require that “able-bodied” adults on Medicaid without children participate in job training or some form of community engagement for at least five hours a week. The requirement would increase to 20 hours a week after a year on the program.
The state estimates the work requirement would save the state and federal government $2.4 billion over five years.
“The program offers opportunities for individuals to take control of their life through taking an active role in not only their health, but also in their communities by working to gain skills needed for long-term independence and success,” Kentucky officials wrote in the state’s application to CMS.
Experts counter that the majority of Medicaid recipients already work; many of those who don’t would be exempt from work requirements because they are children, disabled, elderly or pregnant.
“Most of the people who are getting Medicaid are working themselves or are in working families, so this is targeting a very small percentage of people who are receiving the benefits,” said Dee Mahan, director of Medicaid initiatives at Families USA, a health care advocacy group in D.C.
According to the Kaiser Family Foundation (KFF), eight in 10 Medicaid recipients are in working families, while 59 percent of recipients are working themselves. Those not working say there’s a major impediment to doing so, according to KFF. Thirty-five percent cite an illness or disability that prevents them from work, while 28 percent say they are taking care of family, 18 percent say they’re in school, 8 percent say they’re looking for work and 8 percent are retired.
Experts warn that, if states are granted the waivers, even people who have jobs or otherwise meet the requirements could still lose their Medicaid coverage.
“If you’re exempt, how do you know that? You might be able to be exempt, but does someone tell you it looks like you might have a medical condition that exempts you?” said Robin Rudowitz, associate director for KFF’s program on Medicaid and the uninsured.
“You just might not know about the new requirement or the potential to be exempt, or how to go about the request.”
If the Trump administration is forced to defend the waivers in court, success is far from assured.
One problem is that the states seeking to impose the work requirements have projected that fewer people will be enrolled in Medicaid over time.
“I think every one of these proposals actually projects fewer people being covered, which in my mind runs counter to the objectives of the program and the intent of the [ObamaCare’s Medicaid] expansion, which was to cover people who were otherwise ineligible,” said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.
Adding to the challenge, Verma has made clear she opposes ObamaCare’s Medicaid expansion, which 32 states have used to extend eligibility to more low-income adults.
“She has been very clear she disagrees with the expansion of Medicaid … That’s the law. You don’t get to say you disagree and because you disagree you can impose requirements,” Solomon said.