Ten states have already said that they will pursue the new work-for-Medicaid waivers, according to the administration.
"Medicaid needs to be more flexible so that states can best address the needs of this population", Seema Verma, administrator of the Center for Medicare and Medicaid Services, said in a statement. However, it is highly likely that once any of these waivers are approved, there will be a legal challenge on the work requirement piece.
Kentucky, where the uninsured rate for low-income adults plummeted under the Medicaid expansion (from almost 40% in 2013 to 7% at the end of 2016), estimates its proposed changes will cut enrollment by 15% in five years.
Requirements could involve forcing recipients to prove they are actively seeking work, volunteer their time to community service if they cannot find work, or undergo job training programs.
In a speech to state Medicaid officials in November, Verma indicated that the Trump administration would be receptive to work requirements and other conservative policy ideas to reshape Medicaid.
"This is a shift from prior agency policy regarding work and other community engagement as a condition of Medicaid eligibility or coverage, but it is anchored in historic CMS principles that emphasize work to promote health and well-being", the guidance said.
Contrary to the right-wing trope that recipients of Medicaid are unemployed moochers, a Kaiser Family Foundation study published last month found that 80 percent of adult Medicaid recipients "live in working families, and a majority are working themselves". An analysis at the by Rosenbaum for the Commonwealth Fund on Thursday noted that several of the 10 states who had submitted work requirement plans projected they would reduce coverage.
It is illegal because it contravenes Medicaid's goal of providing medical assistance to low-income and vulnerable people. States should ensure that career planning, job training, referral, and volunteering opportunities are considered to meet the community engagement and job requirement, and that people's employability and potential contributions to the labor market should be factors taken into account. Eligibility for the program varies from state to state, but the national median income limit for a single person to qualify for Medicaid is $16,642 a year.
But opponents to tying Medicaid to work argue that good health leads to the ability to hold down a job.
In his State of the State address Tuesday, Gov. Phil Bryant of MS, a Republican, said he supported a "workforce requirement" for able-bodied adults on Medicaid. "Work requirements impose an additional, unnecessary barrier to allowing patients access to vital health care services for people who need access and coverage the most".
"This action by the Trump administration goes after people who are just trying to get by", said Democratic U.S. Senator Ron Wyden of Oregon. The current request would require able-bodied adults without dependents to work at least 20 hours a week.
Children, the elderly, those with disabilities and pregnant women would be excluded from the work requirement, which would apply only to able-bodied adults. The Arizona application calls for adding both work requirements and five-year lifetime limits on Medicaid enrollment. Almost eight in 10 adult beneficiaries who aren't disabled live in working families; most are working themselves.
"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. "AHCCS isn't created to track people's work status and it's going to cost a lot of money to overhaul the system to ramp up this work requirement".