WASHINGTON (AP) – Rewriting the rules on health care for the poor, the Trump administration said Jan. 11 it will allow states to require “able-bodied” Medicaid recipients to work, a hotly debated first in the program’s half-century history.
Seema Verma, head of the Centers for Medicare and Medicaid Services, said work and community involvement can make a positive difference in people’s lives and in their health.
Advocates, who are increasingly raising their voices to protect health care access for Americans, countered that the move was a radical shift that breaks federal statutes.
“Today’s announcement isn’t about work: It is about taking away health insurance from low-income people,” Eliot Fishman, senior director of health policy at Families USA, a Washington, DC-based health care advocacy group, said in a statement. “This is the latest blow in a continuing campaign to undermine and attack the Medicaid program.”
It is also the latest attempt to reshape Medicaid. Last year, Congress and the Trump administration proposed massive cuts to the program in their budget blueprints, and those proposals could be considered in Congress later this year. The new work-rules plan probably will face strong political opposition and even legal challenges over concerns that some low-income beneficiaries will lose coverage.
Medicaid is a federal-state collaboration covering more than 70 million people, or about 1 in 5 Americans, making it the largest government health insurance program. It was expanded under President Barack Obama, with an option allowing states to cover millions more low-income adults; many have jobs that don’t provide health insurance.
Today, Medicaid covers a wide swath of Americans, ranging from low-wage workers to grandparents. For a picture of what Medicaid is, read Marguerite Casey Foundation‘s Equal Voice News special report, “Health Care in America: The Real Face of Medicaid.”
People are not legally required to hold a job to be on Medicaid, but states traditionally can seek federal waivers to test new ideas for the program.
The administration’s latest action spells out safeguards that states should consider to obtain federal approval for waivers imposing work requirements on “able-bodied” adults. States can also require alternatives to work, including volunteering, caregiving, education, job training and even treatment for a substance abuse problem.
Technically, the federal waivers would be “demonstration projects.” In practical terms, they would represent new requirements for beneficiaries in those states.
The administration said 10 states have applied for waivers involving work requirements or community involvement. They are: Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Advocates for low-income people say they expect Kentucky’s waiver to be approved shortly.
Verma said the goal is to help people move from public assistance into jobs that provide health insurance. “We see people moving off of Medicaid as a good outcome,” she said.
Advocates for low-income people said work has never been a requirement for Medicaid, a program originally intended as a health program for the poor and disabled. Congressional Democrats agreed.
“Health care is a right that shouldn’t be contingent on the ideological agendas of politicians,” said Sen. Ron Wyden of Oregon, the top Democrat on the Senate committee that oversees the program. “Today, the Trump administration has taken a big step in the wrong direction.”
Medicaid now covers a cross-section of people, from many newborns to elderly nursing home residents, and increasingly working adults.
A study from the nonpartisan Kaiser Family Foundation found that most working-age adults on Medicaid are already employed. Nearly 60 percent work either full time or part time, mainly for employers that don’t offer health insurance. Verma said they wouldn’t be affected by the new policy.
Most who are not working report reasons such as illness, caring for a family member or going to school. Some Medicaid recipients say the coverage has enabled them to get healthy enough to return to work.
The debate about work requirements doesn’t break neatly along liberal-conservative lines. Kaiser polling last year found that 70 percent of the public support allowing states to impose work requirements on Medicaid recipients, even as most people in the U.S. were against deep Medicaid cuts sought by congressional Republicans and the Trump administration.
The Jan. 11 administration guidance to states spells out safeguards that states should consider in seeking work requirements. These include:
- Exempting pregnant women, disabled people and the elderly.
- Taking into account hardships for people in areas with high employment, or for people caring for children or elderly relatives.
- Allowing people under treatment for substance abuse problems to have their care counted as “community engagement” for purposes of meeting a requirement.
The administration said states must fully comply with federal disability and civil rights laws, to accommodate disabled people and prevent those who are medically frail from being denied coverage. States should try to align their Medicaid work requirements with similar conditions applying in other programs, such as food stamps.
Verma said work requirements are up to individual states, and allowing them to experiment is within her authority as program administrator.
But Judy Solomon of the Center on Budget and Policy Priorities said federal waiver authority doesn’t provide carte blanche to ignore the basic purposes of the program, and promoting work has not been on that list up to now.
“There’s never been a work requirement in Medicaid. It’s only been in recent years that states have raised the possibility of having one,” she said. “Medicaid is a health program that is supposed to serve people who don’t otherwise have coverage.”
Marguerite Casey Foundation’s senior writer Paul Nyhan contributed to this report.
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