Trump’s Historic Medicaid Shift Goes Beyond Work Requirements
The administration signaled late last year that it welcomes state-based ideas to retool Medicaid and "help individuals live up to their highest potential." At least 10 states have requested waivers that would allow them to impose work requirements and other obligations.
For example: They would require more recipients to contribute small monthly premiums. They would insist on monthly paperwork. They would impose lifetime limits on coverage. And they would kick recipients off Medicaid for a period of time -- 30 days, or perhaps six months -- for failing to follow the rules.
All the states requesting Medicaid work requirements are led by Republican governors who tout the "it's a trampoline, not a hammock" approach to the social services safety net.
In the past few weeks, the Trump administration has granted approval to
In
More Uninsured?
But the imposition of new requirements would reverse some of those gains. It also entails a sharp break from the Obama administration's explicit position that all changes to state Medicaid policies had to "increase and strengthen overall coverage of low-income individuals in the state."
The Trump administration has removed that language as a criterion for approving changes to state Medicaid policies. Instead, the administration announced a different objective for Medicaid.
"We have a higher purpose than just handing out Medicaid cards,"
Verma's speech was a prelude to CMS issuing new guidance in November indicating its openness to state proposals to add work requirements to their Medicaid programs, proposals the Obama administration routinely rejected. Out went increasing access to health care to the poor; in came language about employment leading to better health for enrollees by helping them to "rise out of poverty and attain independence."
Instead of increasing access to Medicaid, the Trump administration said the changes it is pursuing will modify the behavior of beneficiaries to "promote upward mobility, greater independence and improved quality of life."
It's very much in keeping with longtime Republican orthodoxy that safety net programs should be only temporary ports for the poor. The long-term goal should be self-sufficiency. "Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration," Verma said.
Many Republican governors have embraced the shift.
"I firmly believe that every human being aspires to earn her own success. For those whose family situation and health allow it, there is nothing quite as beneficial as the sense of accomplishment that comes from work,"
But the new philosophy has alarmed many who advocate for health care access for the poor. Instead of helping people obtain work, they say the Trump approach will simply deprive people of health care.
"It's such a wrongheaded punitive policy that won't achieve the end goal of putting people to work," said
'Lockouts' and Lifetime Limits
Since 2008, the federal government has given some states, including
In approving lockouts in
But at least one study found that imposing premiums in Medicaid leads to fewer people being covered. In
The half-dozen states that charge premiums now generally apply them only to Medicaid beneficiaries at higher income levels. But some states, such as
CMS also gave
Federal officials also granted
Critics say the Trump administration's philosophy demonstrates either ignorance about or indifference to the hardships and chaos confronting many who live in poverty. Many work multiple jobs, do contract work or are otherwise in situations where hours and fluctuations in income are hard to predict or to document. They may live in situations in which mail delivery is unreliable. They may not have access to computers.
"Many poor people face challenges that will make it very difficult to meet these requirements," said
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