Trump Administration Will Let States Require People To Work For Medicaid

Jan 11, 2018
Originally published on January 11, 2018 10:32 pm

Updated at 11:29 a.m. ET

The Trump administration is encouraging states to require "able-bodied" Medicaid recipients to work or volunteer in order to keep their health insurance coverage.

On Thursday, the Centers for Medicare & Medicaid Services, which is part of the Department of Health and Human Services, issued new guidelines for states that want some adults to work in exchange for the health insurance coverage.

Under the rules, states can require Medicaid beneficiaries to work, volunteer or participate in job training. People who are elderly or disabled, and pregnant women and children, would be excluded.

CMS Administrator Seema Verma said on Twitter that the new efforts will "improve Medicaid enrollee health outcomes by incentivizing community engagement."

"This is about helping people rise out of poverty," Verma said Thursday in a conference call with reporters.

She cited studies that show a correlation between good health and having a job.

But opponents to tying Medicaid to work argue that good health leads to the ability to hold down a job.

"Access to Medicaid makes it easier for people to look for work and obtain employment," says Suzanne Wikle of the Center for Law and Social Policy. "A so-called work requirement does not support work but instead puts a critical support for work at risk."

Ten states — Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin — have already filed applications with CMS to add work requirements to their Medicaid programs.

But it's not clear how many people would be affected by the new rules. A study in December in JAMA Internal Medicine found that about half of the Medicaid recipients in Michigan were already working.

In addition, people who are disabled under the Americans with Disabilities Act but have Medicaid benefits for another reason could be exempted, or the state would be required to make "reasonable modifications" such as a reduced hourly requirement to ensure that the requirements don't disproportionately hurt people with disabilities.

And states are also required to make such accommodations for people with addiction to opioids and other substances. That could mean counting time spent in drug treatment as a form of "community engagement."

The range of community engagement requirements can be quite broad, according to the CMS guidelines sent to states on Thursday. In addition to traditional work and job training, engagement could include caring for a child or elderly parent, seeking treatment for drug addiction or going to school.

Verma said the agency wants to give states as much latitude as possible to try out their own ideas.

"There are a lot of different ideas, and a lot of ways to go about this," she said. "We want to give states as much flexibility as possible because that's where we'll be able to evaluate what actually works best."

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The Trump administration is encouraging states to require people on Medicaid to work for their health benefits. New guidelines issued today say states can make so-called able-bodied adults either work, volunteer or get job training to qualify for the program. It's up to states to define that. The administration says working and participating in society leads to better health, but opponents say it's the other way around. People need to be healthy to hold down a job.

NPR health policy correspondent Alison Kodjak is with us now to talk about this. And Alison, just explain. What exactly do these guidelines say?

ALISON KODJAK, BYLINE: Well, so they came in the form of a letter from Seema Verma, who's the head of the Center for Medicare and Medicaid Services, to the state Medicare, Medicaid directors. And it basically says that the CMS will invite proposals for states to impose work requirements on Medicaid recipients.

They give some examples of what those would be - like you said, work, volunteer work, job training or perhaps caring for an elderly parent or even - they even suggested drug treatment programs could qualify. And then they talked a lot about who the rules can affect and who could and could not be exempted.

MCEVERS: I mean, my understanding is that the majority of able-bodied people on Medicaid already work. So who is likely to be affected by these new rules?

KODJAK: Yeah, and that's true. Right now about 60 percent of people on Medicaid who aren't deemed disabled have jobs. And the rules say anyone who's medically frail or has an acute illness is exempt. And people caring for minor children could be exempted.

And then there's this whole population of people who are able-bodied in the context of Medicaid, meaning they get Medicaid benefits for a reason other than disability, but they might be considered disabled by the Americans With Disabilities Act. And the guidelines say they have to take that into account as well. So I've read a couple of example - analyses that say basically only about 3 to 10 percent of the people on Medicaid could even be affected by this rule.

MCEVERS: States have to apply for a waiver if they want to impose these work rules. Are they likely to do it, and how soon could we see actual work requirements go into effect?

KODJAK: Yeah. So actually, 10 states already have applied for these waivers.


KODJAK: They include Michigan, Kentucky, Arizona, Indiana - you know, several more because earlier this year, Seema Verma told state Medicaid administrators that she was open to this idea and that these rules would be coming. And we could see some results pretty soon 'cause there are rumors swirling that by tomorrow, Kentucky's application could possibly be approved.

MCEVERS: What is in that application?

KODJAK: It follows along with what we've been discussing. Adult on Medicaid would have to work, volunteer, get training or even take a GED class for 20 hours a week in order to keep their benefits. And they do have a list of exempt rules that include people with acute illnesses. So it follows along with the guidelines that were sent out today.

MCEVERS: The Centers for Medicare and Medicaid Services in allowing these rules is saying that working leads to better health. Is there evidence to back that up?

KODJAK: Well, CMS is asserting that, and they have cited several studies in their guidelines. But those studies really just show a correlation. They show that people with jobs and higher incomes are generally healthier than people who don't have them. And that makes sense of course. But there's a bit of a chicken and egg issue. Some people are - there's a question of whether people are unhealthy because they're not working, or are they unemployed because their poor health prevents them from working? And opponents are worried that that's the problem. If they can't become healthy, they won't be able to get a job.

MCEVERS: NPR's health policy correspondent Alison Kodjak, thank you so much.

KODJAK: Thank you, Kelly. Transcript provided by NPR, Copyright NPR.