For now, congressional Republicans appear to have set aside efforts to repeal the Affordable Care Act (ACA). Yet, it’s increasingly clear that the Trump administration is doubling down on its attempts to seriously weaken the ACA’s Medicaid expansion by making it more difficult for millions of low-income people to get health coverage. The administration’s strategy is focused on state waivers, which do not require congressional approval. On Monday, the administration approved a sweeping new waiver in Arkansas that could jeopardize coverage for many low-income adults.
Trump administration officials Mick Mulvaney (budget director) and Seema Verma (administrator of the Centers for Medicare and Medicaid Services, or CMS) both oppose the Medicaid expansion, and Verma approved state proposals that will make it much harder for many who gained coverage under the expansion to maintain it.
Thus far, the Trump administration has approved three broad, restrictive waivers — in Kentucky, Indiana and now Arkansas. All three waivers include a work requirement that will, for the first time, allow these states to take coverage away from those who aren’t working or participating in work-related activities for a minimum number of hours per month, without providing any new job search assistance, job training, transportation, child-care, or other services that could help people find and hold a job. CMS calls this “helping people rise out of poverty and live the American Dream”.
This policy is backward for many reasons. Most adults with Medicaid coverage already work and most of those who don’t are caregivers, in school, or unable to work because of an illness or disability. The work requirements will probably cause many of these low-income adults to lose coverage. Some won’t be able to overcome the various bureaucratic hurdles to document that they already meet work requirements and work the requisite number of hours; others will struggle to document that they qualify for an exemption from the requirements.
That’s why we and others (including many health-care providers, such as the American Medical Association) have sounded deep concerns about these work requirements’ potential impact on people covered by Medicaid. (We’ve also documented how important Medicaid coverage is to its beneficiaries.)
But the waivers also include other harmful provisions that have gotten less attention and that, like the work requirements, will undermine access to care for many people. For example, CMS is letting states impose premiums and substantial cost-sharing changes on people in poverty, which Medicaid has historically prohibited because of the robust research showing that they discourage people from enrolling in Medicaid and obtaining needed health care.
The waivers also lock adults out of Medicaid coverage entirely for a time if they don’t renew their eligibility or update the state on a change in their income (such as a change due to their employer temporarily modifying their work hours) within a very short window. For a low-income single mom juggling multiple jobs and family responsibilities, these punitive requirements could lead to cutoffs in coverage for nine months.
CMS also is considering a slew of other waivers with provisions that would break all precedent and further reduce coverage. These include state proposals to impose lifetime limits on Medicaid coverage, as though low-income people only need health coverage for a few years out of a lifetime. These lifetime limits could apply even if the person is working, as are most expansion enrollees, and could make it even harder for them to keep their jobs.
Over time, these limits are likely to harm older people the most, since anyone who has lost their job during a recession could exhaust their Medicaid eligibility before they turn 65. If they lose their job again before they’re eligible for Medicare, they could have nowhere to turn when their health-care needs are greatest and individual market coverage is most costly.
Another such proposal would allow drug testing as a condition of Medicaid eligibility. Considering the sharp increase in opioid-use disorders, this terribly misguided change could block access to treatment from those who clearly need it.
The federal government is being sued over Kentucky’s waiver, and further suits will probably follow from other states where such waivers are approved. It is possible that these suits could prevent states from implementing some of these harmful provisions. But they won’t close the door the Trump administration has opened to states aiming new restrictions at adults with Medicaid coverage, despite Congress’s rejection last year of bills that would repeal the Medicaid expansion.
The administration has claimed that changes like these are needed to “preserve Medicaid for future generations.” Such claims are untenable given the enactment of their regressive tax plan, financed by $1.8 trillion in deficit spending (including interest costs). As these tax benefits begin to get doled out, mostly to the wealthy, poor families in Kentucky, Indiana and Arkansas are facing premiums for Medicaid that many will find unaffordable, unnecessary work requirements and a temporary loss of coverage if they forget to document almost immediately the extra hours they worked last month.
If the Trump administration really wanted to help more Medicaid enrollees to work, they’d protect the coverage of working-age people, since health coverage often provides people with the treatment they need to participate in the workforce. Instead, just like their earlier, legislative efforts, their real motivation is to sharply reduce access to Medicaid coverage. Such efforts must be exposed and resisted.