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Undeterred by Medicaid Rulings, States and Trump Advance Work Requirements

Even though a federal judge put the policy's legality in doubt, the Trump administration approved Utah's work requirement waiver on Friday. Meanwhile, Indiana already started phasing them in, and isn't stopping.

Arkansas Gov. Asa Hutchinson
Arkansas Gov. Asa Hutchinson discussing the state's request to add work requirements to Medicaid, which was approved earlier this year.
(AP/Andrew DeMillo)
Last Updated March 29 at 2:13 p.m. ET



  • On Wednesday, a federal judge struck down Medicaid work requirements in Arkansas and Kentucky.
  • The governor of Arkansas urged the Trump administration to appeal the ruling.
  • Indiana, which already started phasing work requirements in, doesn't plan to stop.
  • On Friday, CMS approved Utah's work requirement waiver. 
On Wednesday, a judge struck down Arkansas and Kentucky's Medicaid work requirement programs, throwing the future of the conservative health policy -- and Medicaid expansion at large -- into question. 

U.S. District Judge James Boasberg’s ruling blocks Kentucky from implementing its program -- which was the first approved by the Trump administration in January 2018 -- and puts an end to Arkansas’ program, which has been running since June and has led to the loss of health care for tens of thousands of people.

In a case expected to reach the U.S. Supreme Court, Judge Boasberg ruled that “Medicaid is an entitlement” and that the defendants “did not address ... how the project would implicate the 'core' objective of Medicaid: the provision of medical coverage to the needy."

The federal government signaled on Wednesday that the rulings won’t slow down its approval of state’s requests for work requirements. In fact, on Friday, the feds approved Utah's work requirement waiver, which could overrule a ballot measure passed by residents in November to expand Medicaid without work rules. Six other states -- largely ones that didn’t expand Medicaid -- still have work requirement waivers pending with the federal government.

“States are the laboratories of democracy, and we will vigorously support their innovative, state-driven efforts to develop and test reforms that will advance the objectives of the Medicaid program,” said Seema Verma, administrator of the Centers for Medicare and Medicaid Services (CMS), in a statement on Wednesday.

The Republican governor of Arkansas, Asa Hutchinson, urged the Trump administration -- the defendant in the case -- to appeal the ruling.

“I contend that the judge is wrong,” he said during a press conference Thursday. “If we want to continue the fight, the best course is to appeal.”

Hutchinson acknowledged that 18,000 people have lost health coverage since the work requirements went into effect, but he said 90,000 people have also "moved off" Medicaid since the state expanded the program in 2013.

Gov. Matt Bevin of Kentucky, also a Republican, has previously vowed to end the entire Medicaid expansion program -- which would cut 400,000 people off from their health insurance -- if he can't implement work requirements. He has yet to comment on the latest ruling.

Work requirements for Medicaid, the nation's health insurance for the poor, sprang up after the passage of the Affordable Care Act, President Barack Obama's signature legislation. The law allows and helps states offer Medicaid to more low-income people. The federal government initially pays 100 percent -- and eventually 90 percent -- of the costs of expanding eligibility to people earning 138 percent of the federal poverty line.

Most of the early adopters of Medicaid expansion were Democratic-led states. Some Republican-led states have slowly expanded coverage, but most of them have added a work requirement for nondisabled people -- a policy that the Obama administration repeatedly rejected. Under the Trump administration, CMS has approved work requirement waivers for Arkansas, Arizona, Indiana, Kentucky, Michigan, New Hampshire, Ohio and Wisconsin.

Work requirements are in effect in two other states -- Indiana and New Hampshire.

New Hampshire implemented work requirements in March, but they are being challenged in court by the National Health Law Program, the New Hampshire Legal Assistance and the National Center for Law and Economic Justice. The lawsuit was filed earlier this month. 

Indiana phased in work requirements in January, but beneficiaries don’t have to start reporting their hours until July and those in noncompliance won’t start losing coverage until January 2020. For that reason, officials say their program has better protections in place and that they aren’t changing their course of action.

“We worked with providers, stakeholders and members to develop the Gateway to Work program and continue to take feedback to make improvements. We are using an extended ramp-up period to educate and engage members how to successfully report work, job training, education or community engagement activities,” said Jim Gavin, spokesperson for Indiana’s Family and Social Services Administration, in an email on Thursday.

It’s not just the future of Medicaid that’s uncertain. Earlier this month, the U.S. Department of Justice reversed course and threw its support behind a recent ruling that the entire Affordable Care Act should be struck down. If this case goes back to the Supreme Court, the fate of the landmark law would be in jeopardy. 

Mattie covers all things health for Governing.

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