Since the Trump administration greenlit state governments in January to add work requirements to their Medicaid programs, many conservative states have seized on the opportunity. The concept of making work a requirement for people living in poverty to get free health insurance is a controversial one. But the exceptions to these work requirements are generating controversy of their own.

In Kentucky, Michigan and Ohio, Republicans -- who control the legislature in those states -- have proposed exempting counties with high unemployment from the work requirements.

Supporters argue that work requirements will incentivize people to get or stay employed and eventually stop using Medicaid. Generally speaking, the counties that would be relieved from the proposed exemptions lack jobs and public transportation.

Critics, which are mostly Democrats, don't like that work requirements would leave some people uninsured -- but they also don't like the unemployment exemption because they say it would give a pass to predominantly white rural counties and not urban areas with majority-black populations.

An analysis by The Washington Post found that exempting Michigan's high unemployment counties -- but not cities -- would disproportionately impact black and white people. Black people make up 23 percent of the population subject to a work requirement but only 1.2 percent of the population that would be eligible for the exemption. White people, meanwhile, make up 57 percent of the population subject to a work requirement but 85 percent of the population that would be eligible for the exemption.

Take Detroit and Flint, for example. Both majority-black cities have unemployment rates above 8.5 percent, which is the threshold for triggering an exemption. But because they are in counties with an average unemployment rate below 8.5 percent, they are not shielded from the work requirement.

Only a narrow slice of Michigan's Medicaid population -- regardless of race -- would be protected by the unemployment exemption. The Center on Budget and Policy Priorities (CBPP), a left-leaning think tank, found that only 3 percent of Michiganders facing the new work requirement live in high unemployment counties. The CBPP has called the bill "unfixable."

Two law professors from the University of Michigan raise the possibility that the unemployment exemption could violate residents' civil rights. The professors also question the underlying premise of providing relief from work requirements based on geography.

"If work requirements were a good idea, conservative Michigan legislators wouldn’t need to exempt their rural constituents," they wrote.

Medicaid would not be the first federal safety net program where work requirements can be waived for certain geographic areas. States are allowed to seek similar work requirement waivers for food stamps -- though the Trump administration has proposed eliminating some of those.

Nevertheless, the Michigan Legislature has since abandoned the exemption for counties with high unemployment, saying it would have been too difficult to administer. But the bill's sponsor, Republican state Sen. Mike Shirkey, denied that the criticism about inequitable racial or geographic impacts killed the exemption.

"While it may have been a good idea, it's not a good idea from the standpoint of complexity and ability to administer. So that's the reason it's being removed," he told the Detroit Free Press. "It has nothing to do with these ridiculous claims."

Meanwhile, the policy still has a chance elsewhere.

States need federal approval to implement work requirements and any exemptions to them. Ohio submitted its waiver request this month. Kentucky won federal approval but is facing a court challenge that could block the changes from going into effect.

In Michigan, the legislature still plans to send a bill to GOP Gov. Rick Snyder that would add work requirements but have no exceptions for counties with high unemployment. In April, Snyder called the Senate version of the bill "neither a reasonable nor responsible change to the state’s social safety net," but he stopped short of saying he would issue a veto.

Flint Mayor Karen Weaver is among the critics of work requirements. She worries that having fewer people insured will hamper her city's ability to address ongoing public health problems related to lead poisoning in Flint's water. Out of about 700,000 Medicaid beneficiaries who would be subject to the work requirement in Michigan, roughly 105,000 are expected to lose coverage. Weaver called on Snyder to veto the work requirement legislation.

"Medicaid is a health program and not a jobs program," she wrote.

Michigan's bill would require an average of 29 hours a week of certain work activities, such as employment, education and job training, to qualify for Medicaid coverage. For those found to be out of compliance, the state would issue a warning and give 30 days to fulfill the work requirement -- or else lose Medicaid for a year.

All this controversy comes amid a larger national debate over Republican proposals in Washington to radically reshape several of the largest federal anti-poverty programs.

The Trump administration has called for adding work requirements to federal housing assistance. The recently defeated House farm bill would have imposed stricter work requirements on more food stamp recipients, including parents of school-aged children.

As for Medicaid work requirements, the federal government has approved waivers for them in Kentucky, Indiana, Arkansas and New Hampshire. Another six states have pending applications. Michigan could be next.

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