The Hill reports that the Trump administration will soon release guidelines for states that wish to add work requirements for certain populations in their Medicaid programs.


The Trump administration has already given numerous signals that it will be encouraging of states, such as Arkansas, that seek to impose work requirements on their Medicaid expansion programs. Governor Hutchinson submitted a request for a waiver of Medicaid rules, which included a request for work requirements, last summer. Arkansas is one of nine states currently seeking such waivers for work requirements. While the Obama administration refused to okay such requirements, approval is expected from the Trump administration.

The new federal guidance, the Hill reports, will establish conditions and protocols for states that wish to go this route (it will still require a waiver). The guidance is expected within weeks. One possibility is that the Trump administration wishes to release the guidance at the same time or prior to approving pending waiver requests like that of Arkansas, which are likely to face immediate legal challenges. (Hutchinson had hoped to get approval months ago so that his proposed changes could be implemented on Jan. 1.)


By law, waivers must promote the objectives of Medicaid, which is a health care program. Legal challenges will assert that work requirements do nothing of the kind and are in fact counterproductive to Medicaid’s goals.

From the Hill story, here’s Eliot Fishman, who was a Medicaid official in the Obama administration and now works for the advocacy group Families USA:


The guidance is an attempt to put the administration’s preferred legal framing around the waiver approvals, in anticipation of likely legal challenge in the federal courts. Given that the legal standard is whether the waivers ‘promote the objectives’ of the Medicaid program, that the basic objective of the program is to cover low-income people, and that these waivers will take coverage away from low-income people, they will have a tough legal case to make.

The Hill reports that Kentucky is likely to be the first state to waiver approval, which echoes what I’ve heard from Medicaid waiver observers.

Most Medicaid expansion beneficiaries currently work already; recent research suggests many of those who do not work are in poor health, including significant numbers who have serious physical or mental health problems that preclude them from working. Critics of Medicaid work requirements argue that kicking people who struggle to keep up with the requirement off of their insurance will expose vulnerable populations to risks to their health, and that such requirements will impose bureaucratic hoops and red tape that lead to gaps in coverage.

Hutchinson’s waiver proposal would impose work requirements on many beneficiaries in the state’s Medicaid expansion program, which covers low-income adults. Those between the ages of 18-49 would be required to work 80 hours per month; if they are not working, they would have to participate in job training programs, job searches, or certain approved volunteer activities. Beneficiaries must be in compliance for nine months out of the year or they would be removed from the program for the duration of the year.

Beneficiaries 50 or older would not be subject to the work requirement. Exemptions would be available for others who met certain criteria, including full-time students, those caring for an incapacitated person, those caring for dependent children in the home, people receiving unemployment benefits, those who are medically incapacitated due to physical or mental health problems, those participating in a drug or alcohol addiction treatment program, and pregnant women. The state’s Department of Human Services projects that around half of Arkansas Works beneficiaries would be eligible for an exemption.


Non-exempt beneficiaries will have to report their work activity on a monthly basis. They will do so via a website, which is still under development; kiosks will be available in county offices for people who can’t access the site via a computer or other device. Both the DHS and insurance companies will send notices, including emails, if someone is noncompliant, reminding them to report.

The DHS has said that it will take 60 days to implement the changes once federal approval is secured.