After passing the Trump tax cuts late last year, the White House revealed that immigration, welfare reform and the administration’s nascent infrastructure plan would be its top priorities in 2018.
And while lawmakers say they’re close to a tentative immigration compromise to preserve DACA protections by packaging them with a border-security package that will presumably include some funding for the president’s promised border wall, the White House is already starting its crackdown on Medicaid.
To wit, the administration issued guidance early Thursday that will force people trying to collect Medicaid that they are working, or preparing to work. The policy change, according to the Washington Post, is the biggest blow to Medicaid in the program’s 50-year history.
However, it’s widely expected that any attempts to implement this policy will be met with a court challenge by the states, which administer Medicaid, and advocacy groups.
To be sure, 10 states are already lined up to adopt the new policy. They’re just waiting for federal permission to impose work requirements on able-bodied adults in the medicaid program.
Furthermore, three other states are contemplating them. Health officials could approve the first waiver - probably for Kentucky - as soon as Friday, according to two people with knowledge of the process.
As WaPo explains, the trend of imposing limits on Medicaid began two decades ago when a system of unlimited cash assistance was replaced by the Temporary Assistance for Needy Families.
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 health care.
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.
Despite promising during the campaign to leave Social Security, Medicaid and Medicare untouched, Trump has more recently signaled that he would seek to limit access to benefits for a program that was adopted as part of President Lyndon Johnson’s Great Society programs.
That tone was cemented in March when the newly sworn in 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."
Government lawyers cautioned that they would need time to establish a legal justification for the new requirements that could withstand a court challenge. Apparently, the prevailing view adopted by conservatives is that working “promotes good health” which they can use to justify that this policy change would “further the objectivs” of Medicaid.
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.
"[A] growing body of evidence suggests that targeting certain health determinants, including productive work and community engagement, may improve health outcomes" the letter says. "While high-quality health care is important for an individual’s health and well-being, there are many other determinants of health."
If the first approvals are issued this week, expect the first court challenges to arrive immediately after.
"This is going to go to court the minute the first approval comes out," predicted Matt Salo, executive director of the National Association of Medicaid Directors.