In a major departure from more than 50 years of US healthcare policy, the Trump administration will let states move towards imposing work requirements on people as a condition for obtaining health insurance under the Medicaid government program for the poor.
The proposed change will allow states to deny access to Medicaid – the largest single health insurance provider in the country – to certain low-income adults, as part of a sweeping welfare reform that many Republicans have demanded for years.
A letter from Centres for Medicare and Medicaid Services (CMS) deputy administrator Brian Neale declared the Trump administration was “incentivising work and community engagement” by allowing states to exempt certain adults from the programme if they were not working or participating in “community engagement”.
“Subject to the full federal review process, CMS will support state efforts to test incentives that make participation in work or other community engagement a requirement for continued Medicaid eligibility or coverage,” said the letter, which was sent to state Medicaid directors on Thursday morning.
More than 70 million Americans depend on Medicaid for health insurance, according to the Kaiser Family Foundation. While other social safety nets – such as welfare and food stamp programmes – have been reformed over the years to include work requirements, healthcare access has been viewed by most policy experts as a right.
Under the new rules, however, states can apply for a waiver to impose work requirements on Medicaid beneficiaries. Ten states have already applied for a waiver and three more are considering doing so, according to the Washington Post. The Trump administration could approve the first waiver as early as Friday.
When applying for a waiver, states must justify how the work requirement would “further the objectives” of Medicaid, according to the letter. They must also allow elderly people, pregnant women, people with disabilities, and those “determined by the state to be medically frail” to be exempted from the requirement. Special consideration must also be given to those struggling with opioid addiction.
Beyond that, states have large flexibility to determine what counts as “employment”. The Department of Health and Human Services suggests, but does not require, that activities such as community service, care giving, education, job training, and substance use disorder treatment count towards the requirement.