Med­i­caid work re­quire­ment rewrites health care rules


WASH­ING­TON — 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 low­in­come 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 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: 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.

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 un­em­ploy­ment, 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.”

AP photo

Med­i­caid ad­min­is­tra­tor Seema Verma listens as Pres­i­dent Donald Trump speaks dur­ing a meet­ing in Wash­ing­ton. The Trump ad­min­is­tra­tion said Thursday it’s of­fer­ing a path for states that want to seek work re­quire­ments for Med­i­caid re­cip­i­ents, a ma­jor change to cur­rent rules.

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