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story.lead_photo.caption Seema Verma, left, administrator of the Centers for Medicare and Medicaid Services, is shown with former White House aide Omarosa Manigault during a Health and Human Services listening session on the Affordable Care Act, in the Roosevelt Room of the White House, June 21, 2017.

WASHINGTON -- President Donald Trump's administration said Thursday that it would allow states to impose work requirements on some Medicaid recipients, a policy shift in the health program for low-income people.

Federal officials said they would support state efforts to require able-bodied adults to engage in work or "community engagement activities" as a condition of their eligibility for Medicaid.

"Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries, and today's announcement is a step in that direction," said Seema Verma, the administrator of the federal Centers for Medicare and Medicaid Services.

Medicaid beneficiaries range from pregnant women and newborns to elderly nursing-home residents. Medicaid was expanded under former President Barack Obama, with an option allowing states to cover millions more low-income adults. Many of them have jobs that don't provide health insurance.

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People on Medicaid are not legally required to hold jobs, but states traditionally can seek federal waivers to test new ideas for the program.

Verma said the Trump administration was responding to requests from Medicaid officials in 10 states that wanted to test requiring recipients to work or participate in training, education, job search, volunteer activities and caregiving. One of those states was Arkansas.

With Thursday's announcement, Trump administration officials are moving to fulfill a conservative vision for one of the nation's largest social insurance programs: adding work requirements to receive Medicaid that are similar to those imposed in other programs such as food stamps and the welfare program known as Temporary Assistance for Needy Families.

Trump's new direction can be reversed by a future administration.

In a speech to state Medicaid officials in November, Verma indicated that the Trump administration would be receptive to adding work requirements and considering other conservative policy ideas to reshape Medicaid. She criticized the Obama administration, saying it had focused on increasing Medicaid enrollment rather than helping people move out of poverty and into jobs.

"Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration," Verma said. "Those days are over."


Proposals to add a work requirement in Medicaid came from Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Several other states are considering such work requirements.

In Arkansas, state Department of Human Services spokesman Amy Webb said the government's guidance "seems to be in line with how we want to move in Arkansas."

"We're really optimistic that we'll get official waiver approval very soon," she said.

The state's previously submitted proposal would require enrollees in Arkansas Works -- the state's expanded Medicaid program -- to spend at least 80 hours a month on work or approved activities, such as taking classes, looking for jobs or volunteering.

The requirement, modeled after the work requirement for the state's food stamps program, would initially apply to enrollees ages 30-49 and would then be extended to those ages 19-29.

Enrollees 50 and older would be exempt, as would those who are pregnant, living with dependent children, receiving welfare benefits, caring for an "incapacitated person," or participating in a drug or alcohol treatment program.

More than half of Arkansas Works enrollees would likely qualify for an exemption, Human Services Department officials have said.

The state also has proposed moving about 60,000 people off Arkansas Works by limiting eligibility to people with incomes of up to the poverty level, instead of 138 percent of the poverty level.

More than 285,000 Arkansans were enrolled in the Medicaid program as of Jan. 1.

Across the country, advocates for Medicaid beneficiaries said the new policy was likely to be challenged in court if people were denied coverage for failure to meet a state's work requirement.

Federal law gives the secretary of Health and Human Services broad authority to grant waivers for state demonstration projects that "promote the objectives" of the Medicaid program. In the past, federal officials said work was not among those objectives.

But Trump administration officials said Thursday that work requirements are consistent with the goals of Medicaid because work and work-related activities could improve the health of Medicaid beneficiaries.

"Productive work and community engagement may improve health outcomes," Brian Neale, the director of the federal Medicaid office, said Thursday in a letter to state Medicaid directors. "For example, higher earnings are positively correlated with longer life span."

In addition, Neale said, researchers have found "strong evidence that unemployment is generally harmful to health," while employment tends to improve "general mental health."

Federal and state officials and health policy experts said Medicaid beneficiaries could work at a variety of jobs -- as cashiers, telemarketers, housekeepers, nursing and home health aides, child care providers, cooks and dishwashers, waiters and waitresses, retail sales clerks, landscapers, security guards and construction laborers, for example. They could also work as volunteers at food pantries and other charitable organizations.

The Trump administration said states imposing work requirements must have plans to help people meet those requirements and should help arrange job training, child care and transportation as needed. But, it said, states cannot use federal Medicaid funds to pay for such "supportive services."


Medicaid has played a big role in combating the opioid epidemic, paying for a wide range of treatments and medications. But people addicted to opioids are often unable to work or to find jobs, and some employers are reluctant to hire people who fail drug tests.

Verma said the Trump administration would require states to make "reasonable modifications" of their work requirements for people who are addicted to opioids or have other substance use disorders.

For example, she said, time spent in medical treatment for opioid addiction might be counted toward compliance with a state's work requirement. Alternatively, she said, states could exempt people from the work requirement if they were participating in "intensive medical treatment" for addiction.

The Trump administration said state Medicaid officials could not impose work requirements on pregnant women, elderly beneficiaries, children or people who are unable to work because of disabilities. States must also create exemptions for people who are "medically frail."

Despite such exemptions, Democrats called the new policy inhumane and mean-spirited, echoing criticism of work requirements in a welfare law adopted in 1996.

Rep. Frank Pallone, D-N.J., said "the Trump administration's action today is cruel and a clear violation of both the Medicaid statute and long-standing congressional intent" for waivers, which he said were meant to "allow states to expand access to Medicaid, not restrict it."

But the new policy is exactly what some Republican governors were seeking.

In his State of the State address Tuesday, Gov. Phil Bryant of Mississippi, a Republican, said he supported a "workforce requirement" for able-bodied adults on Medicaid.

"This is not, as some would have you believe, a punitive action aimed at recipients," Bryant said. "It will actually help this population reap the rewards of a good job, and one day receive health care coverage from their employer, not the state or federal government."

The National Association of Medicaid Directors, a nonpartisan group representing state officials, said in a statement that there's no consensus on whether work requirements are the right approach.

"This is a very complex issue that will require thoughtful and nuanced approaches," said the group.

Information for this article was contributed by Robert Pear of The New York Times; by Ricardo Alonso-Zaldivar and Bruce Schreiner of The Associated Press; and by Andy Davis of the Arkansas Democrat-Gazette.

A Section on 01/12/2018

Print Headline: U.S. to allow states' strings for Medicaid; Intent is work requirement for some receiving benefits

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