The Trump administration issued guidance to states early Jan. 11 that will allow them to compel people to work or prepare for jobs in order to receive Medicaid for the first time in the half-century history of this pillar of the nation’s social safety net.
The letter to state Medicaid directors opens the door for states to cut off Medicaid benefits to Americans unless they have a job, are in school, are a caregiver or participate in other approved forms of “community engagement”—an idea that some states had broached over the past several years but that the Obama administration had consistently rebuffed.
The new policy comes as 10 states are already lined up, waiting for federal permission to impose work requirements on able-bodied adults in the program. Three other states are contemplating them. Health officials could approve the first waiver—probably for Kentucky—as soon as Jan. 12, according to two people with knowledge of the process.
The guidance represents a fundamental and much-disputed recalibration of the compact between the government and poor Americans for whom Medicaid coverage provides a crucial pathway to healthcare.
The idea of conditioning government benefits on “work activities” was cemented into welfare more than two decades ago, when a system of unlimited cash assistance was replaced by the Temporary Assistance for Needy Families with its work requirements and time limits. The link between government help and work later was extended to anti-hunger efforts through the Supplemental Nutrition Assistance Program, as food stamps are now called.
But most health policy experts, including a few noted conservatives, have regarded the government insurance enabling millions of people to afford medical care as a right that should not hinge on individuals’ compliance with other rules.
The Trump administration has signaled from the outset that it wanted to set a more conservative tone for Medicaid, a 1960s-era program that was part of Lyndon Johnson’s anti-poverty Great Society. On the day in March when she was sworn in as administrator of the Centers for Medicare and Medicaid Services, Seema Verma dispatched a letter to governors encouraging “innovations that build on the human dignity that comes with training, employment, and independence.”
While some conservatives pressed her agency to quickly issue guidelines, lawyers within the Health and Human Services and Justice departments jockeyed for time to construct a legal justification that they hope can withstand court challenges.
The legal issue is that states must obtain federal permission to depart from Medicaid’s usual rules, using a process known as “1115 waivers” for the section of the law under which the program exists. To qualify for a waiver, a state must provide a convincing justification that its experiment would “further the objectives” of Medicaid.
Unlike the 1996 rewrite of welfare law, which explicitly mentions work as a goal, Medicaid’s law contains no such element, and critics contend rules that could deny people coverage contradict its objectives. To get around this, the 10-page letter argues that working promotes good health and repeatedly asserts that the change fits within the program’s objectives. The guidance cites research that it says demonstrates people who work tend to have higher incomes associated with longer life spans, while those who are unemployed are more prone to depression, “poorer general health,” and even death.
The most recent federal figures show that Medicaid enrolls more than 68 million low-income Americans, including children, pregnant women, people with disabilities, and the elderly. Under the Affordable Care Act, the program has expanded in more than 30 states to cover residents with somewhat higher incomes.
In states that now choose to link Medicaid to work, the requirement would apply only to able-bodied adults as defined by each state.