Rewriting the rules on health care for the poor, the Trump administration said Thursday 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 requiring work or community involvement can make a positive difference in people's lives and in their health. 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.
But advocates said work requirements will become one more hoop for low-income people to jump through, and many could be denied needed coverage because of technicalities and challenging new paperwork. Lawsuits are expected as individual states roll out work requirements.
"All of this on paper may sound reasonable, but if you think about the people who are affected, you can see people will fall through the cracks," said Judy Solomon of the Center on Budget and Policy Priorities, which advocates for the poor.
Created in 1965 for families on welfare and low-income seniors, Medicaid now covers more than 70 million people, or about 1 in 5 Americans. The federal-state collaboration has become the nation's largest health insurance program.
Beneficiaries range from pregnant women and newborns to elderly nursing home residents. Medicaid was expanded under former President Barack Obama, with an option allowing states to cover millions more low-income adults. Many of them have jobs that don't provide health insurance.
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.
Verma, who is credited with designing the Healthy Indiana Plan when she worked as a consultant to former Indiana Gov. Mike Pence, stressed that the administration is providing an option for states to require work, not making it mandatory across the country. Her agency spelled out safeguards that states should put in place to get federal approval for their waivers.
States can also require alternatives to work, including volunteering, caregiving, education, job training and even treatment for a substance abuse problem.
The administration said 10 states have applied for waivers involving work requirements or community involvement. They are Indiana, Arizona, Arkansas, 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.
In Kentucky, which expanded Medicaid, Republican state Sen. Damon Thayer said work requirements could lessen the program's impact on the state budget. They also hearken back to the program's original intent, he added, "as temporary assistance to try to help people get back on their feet, not a permanent subsidy for someone's lifestyle, if they're capable of working."
But congressional Democrats said the Trump administration is moving in the wrong direction. "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 Medicaid.
The debate about work requirements doesn't break neatly along liberal-conservative lines.
A poll last year from the nonpartisan Kaiser Family Foundation found that 70 percent of the public supported allowing states to require Medicaid recipients to work, even as most Americans opposed deep Medicaid cuts sought by congressional Republicans and the Trump administration.
Another Kaiser study 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.
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.
Thursday's administration guidance 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 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 in other programs, such as food stamps and cash assistance.
The National Association of Medicaid Directors, a nonpartisan group representing state officials, said in a statement there's no consensus on whether work requirements are the right approach.
"This is a very complex issue that will require thoughtful and nuanced approaches," said the group.
Trump's new direction can be reversed by a future administration. Although waivers can have lasting impact they don't amount to a permanent change in the program. They're considered "demonstration programs" to test ideas. The administration says the impact will be closely evaluated.
"We know that Republicans tend to think of Medicaid more as a welfare program, while Democrats tend to think of it as more of a health insurance program," said Diane Rowland, the Kaiser foundation's leading expert on the program. "It will be interesting to see how states are going to make this work for people."