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Medicaid Expansion: Working for Wellness

Today, nearly 74 million Americans receive medical benefits through Medicaid or CHIP. These low-income programs provide access for individuals to receive affordable medical care and services. Seniors account for 4.6 million of these recipients.

Working for Wellness:

Early this year, the Trump administration triggered a renewed conflict over the Medicaid program debate. As of January 2018, states are permitted to impose work requirements on individuals seeking to benefit from the Medicaid program. After the Supreme Court determined that states could opt in or out of the Affordable Care Act’s Medicaid expansion – upping the cap to 138% of the poverty level for eligibility – many states chose not to take on the added load. The Trump administration’s enticement is targeting states that have not yet opted in. This option gives conservative states a more palatable option over sweeping Medicaid expansion.

Bevin’s On-Board:

The already-expanded state of Kentucky was the first to implement these “community engagement” requirements. Gov. Matt Bevin, who’s platform emphasized his goal of rescinding Kentucky’s Medicaid expansion altogether, altered positions when given the opportunity to attach some strings to the state’s expansion eligibility criteria. Individuals seeking participation in the program, that do not meet one of the exceptions, must also satisfy new requirements for working, volunteering, or other forms of community involvement in order to qualify for benefits.  

The state will now require 80 hours of employment or volunteer work per month. However, some individuals are exempt from the requirement – the medically frail, pregnant women, foster youth, and others with good cause for nonconformity. The new restrictions are imposed upon working-aged Medicaid recipients – those that are between 19 and 64. The state is also applying premiums and coverage lock-outs for noncompliance. One comfort is that 94% of those affected by the new rules already qualify for an exemption of some sort. The other 6% of unemployed able-bodied individuals are the focus of the changes.

One potential negative is that the program requires beneficiaries to keep their information regularly updated. The mandatory, online-only, reporting by recipients is scheduled to begin July 1st, 2018. One serious hurdle for current and potential recipients is that as many as 42% of Kentucky Medicaid recipients lack internet access. Many entitled individuals will risk coverage lock-out for not having reasonable access to reporting features.

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Constitutionality Questioned:

Advocates for 16 individuals, who would lose coverage if the plan was to move forward, have sued the state of Kentucky. Federal questions of constitutionality were heard June 15, in Washington, under Judge Boasberg. The court hopes to have a ruling on the issues prior to Kentucky’s new requirements taking effect July 1.

Other states that have received permission from the Center for Medicare & Medicaid Services for similar restrictions are watching anxiously for the results. Arkansas, Indiana, and New Hampshire were approved for similar restrictions, but have not yet implemented them. Arizona, Maine, Mississippi, Michigan, Utah, and Wisconsin are all seeking similar approvals. The final ruling will have a significant impact upon these states.  

Lifestyle or Limitations?

Proponents of the new work requirement expansion of Medicaid see the program as a temporary aid for low-income individuals – a crutch, not a motorized wheelchair. Opponents of the requirements cite the core principals of the program – to ensure that all citizens have access to healthcare. Opponents argue that wellness equals the ability to work. Proponents argue that unrestricted access to Medicaid discourages improvement of an individuals circumstances.

Over the years, other programs have been established as work-based incentive systems. Welfare, a previously unlimited resource of monthly financial assistance, became Temporary Assistance for Needy Families (TANF). The Food Stamps program, a monthly food subsidy, has become the Supplemental Nutrition Assistance Program (SNAP). Each of those programs have developed work requirements for continued receipt. The Trump administration has now provided the opportunity for states to expand Medicaid through similar work requirements.

On the other hand, the original purpose for the food stamp program stemmed from, not only the desire to provide nutritional support to low-income families, but to distribute a surplus of food after the Vietnam War. Only later did the program’s focus shift primarily to providing nutritional resources for the poor. Welfare began as a supplemental resource for certain categories of people – purposefully excluding most able-bodied, working-age, people. Each program is a “means-tested categorical program,” meaning that only the genuinely poor and unable would be provided with aid.

Medicaid focuses on low-income individuals of certain groups. The Affordable Care Act’s purpose, however, is to provide all individuals with access to affordable medical care. Thus, the conundrum emerges – is it against the fundamental purpose of the Affordable Care Act to deny certain individuals that could work, or is it justifiable to limit its bounds to the unquestionably needy, as other programs have done?

The new requirements also incorporate the rules of the aforementioned programs. Satisfying working requirements for TANF or SNAP will translate to the Medicaid working requirements. Individuals on multiple programs will fulfill employment requirements across the board. This feature would seem to shape the allowable treatment of Medicaid requirements toward the permitted determining factors for these other means-based programs.


Medicaid directs its attention upon low-income individuals. The Affordable Care Act looks at all individuals. If all individuals are entitled to affordable medical care under the ACA, can denial of benefits be justified through means-based determinations? This is where the arguments divide for each side of the debate.

For conservatives, employment gives individuals the opportunity for employer provided medical insurance, or at least the added financial leeway for purchase of benefits. Employment means that more individuals will reduce the need to rely on Medicaid for medical coverage.

For liberals, medical coverage is a fundamental right to all, under the Affordable Care Act – whether the person is willing or able to gain employment. Holding medical coverage in a separate category than SNAP and TANF, liberals see medical coverage as the foundation to grow from poverty, as well as the source of wellness for continued employment. Thus, access to medical care is tantamount to success.

In the days to come, many eager eyes will be awaiting Judge Boasberg’s ruling on the constitutionality of Kentucky’s working for wellness requirements. This decision will affect the interests of the collection of states willing to expand Medicaid with similar restrictions. It will also impact so many current and potential Medicaid recipients. Kentucky’s Governor has made it clear that he plans to repeal the expansion if the limitations are not upheld.

Will Kentucky’s new limitations force able-bodied, working-aged, individuals into employment? Will the stipulations be found to be unjustifiable? Or, will some compromise be found between the two?

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