Friday, January 12, 2018 1:00 am
Door opens to link work, Medicaid
States to be allowed to add eligibility conditions
Amy Goldstein | Washington Post
WASHINGTON – The Trump administration issued guidance to states Thursday that will allow them to compel people to work or prepare for jobs to receive Medicaid for the first time in the half-century history of this fundamental safety-net program.
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 volunteer, 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 today, 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 crucial access 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, which has 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.
Recent polls suggest that the president's GOP constituency overwhelmingly supports the idea, with more than 80 percent of Republicans favoring it, along with a smaller majority of Democrats.
Several congressional Democrats swiftly condemned the new policy. Republican lawmakers were largely silent.
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 President Lyndon Johnson's anti-poverty programs known as the 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 issue guidelines quickly, lawyers within the Health and Human Services and Justice departments jockeyed for time to construct a legal justification that could 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 it says demonstrates that 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.”
The critics are prepared to pounce on that rationale.
“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, whose members reflect a spectrum of views about requiring work.
Once Verma's agency gives one state permission, “we would be looking very, very closely to the legal options,” said Leonardo Cuello, health policy director at the National Health Law Program. “It's not a good idea, and it's illegal.”
Cuello said the argument that work promotes health is “totally contorted. ... It's a little like saying that rain causes clouds. It's more that people (with Medicaid) get care, which helps them be healthy and makes them able to work.”
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 people with incomes of up to 138 percent of the federal poverty level.
In states that now choose to link Medicaid to work, the requirement would apply only to able-bodied adults as defined by each state.