The debate over Medicaid work requirements played out in a federal courtroom Thursday as the Trump administration defended its policies against opponents who say the measures are designed to prevent poor people from participating in the health care program.
D.C. District Court Judge James Boasberg heard oral arguments in two separate cases challenging the administration’s approval of programs in Kentucky and Arkansas requiring people to work or volunteer 80 hours a month to keep their coverage.
The Department of Health and Human Services (HHS) asked Boasberg to dismiss the lawsuits, arguing that the new work rules improve the lives and health of participants by helping them find jobs.
But Boasberg at times appeared skeptical of the administration's argument that its policies meet Medicaid’s objective of providing health care to low-income residents.
“These requirements are intended to make people’s lives better,” said James Burnham, the Department of Justice attorney representing HHS in both cases.
“That’s not the purpose of Medicaid,” Boasberg responded.
He previously blocked Kentucky from implementing similar rules.
Medicaid work requirements are atop the administration’s health care agenda. Under the 2010 Affordable Care Act, states were given the option to expand Medicaid to childless low-income adults who didn’t previously qualify for the program.
The Trump administration argues that “able-bodied” adults should be working instead, and that Medicaid should be reserved for children, people who are pregnant, adults who are disabled and very-low income residents.
Opponents of work requirements say the new rules don’t do anything to improve public health and are instead designed to kick people out of the program.
“What’s going on here is a disagreement that Congress changed Medicaid,” said plaintiff’s attorney Ian Gershengorn, part of a legal team representing people who lost Medicaid coverage under the requirements.
“There’s a hostility to that” and there’s an idea that “some people are less deserving,” he added.
Since Arkansas’s work requirements went into effect last summer, 18,000 people have fallen off Medicaid rolls in the state. Fewer than 2,000 have reapplied for coverage this year.
Burnham argued it’s not clear yet why those people left the program — and that's why it should be allowed to continue until its scheduled expiration in 2021.
“It’s not fair to say they ‘lost’ coverage. We don’t know what happened,” Burnham said.
The programs were approved by the administration under a provision of federal law that allows states to experiment with changes to Medicaid to find ways to improve health outcomes.
Blocking the work requirements program before 2021 could “destroy the experimental value” of Arkansas’s program, cost the state money and confuse people who are already following the requirements, Burnham said.
When Boasberg blocked the Kentucky work requirements from taking effect, he ruled the administration had not adequately considered whether it would cause people to lose coverage. State officials have estimated that 95,000 people could be removed from Kentucky Medicaid under the administration’s preferred approach.
The administration reapproved the Kentucky program in November after accepting more public comments, to show it was considering feedback. Those requirements will take effect April 1 if Boasberg doesn’t block them.
The judge said he aims to issue simultaneous rulings on both cases by the end of March.
Kentucky Gov. Matt Bevin (R) has threatened to completely end Medicaid expansion in the state if the work requirements are blocked in court. The state argues that it can’t afford to cover adults who could otherwise be working, even though the federal government picks up more than 90 percent of the cost to the state.
The requirements in Kentucky are needed to test if the reforms can “make Medicaid more sustainable” without hurting people, Burnham said.
“It’s totally unknown what the effect will be,” Burnham said. “The point of the experiment is to figure out the effect on the Medicaid population.”
Gershengorn, however, told reporters after oral arguments that the drop-off in Arkansas enrollment works against the administration in Kentucky.
“The secretary can't avoid confronting the fact that tens of thousands of people are losing Medicaid coverage,” he said, referring to Health and Human Services Secretary Alex Azar. “So it impacts the Kentucky analysis quite substantially.”