As the Trump administration moves aggressively to allow more states to impose mandatory work requirements on their Medicaid programs, several states have come under fire for crafting policies that would in practice shield many rural, white residents from the impact of the new rules.

In the GOP-controlled states of Kentucky, Michigan, and Ohio, waiver proposals would subject hundreds of thousands of Medicaid enrollees to work requirements, threatening to cut off their health insurance if they can’t meet an hours-per-week threshold.

Those waivers include exemptions for the counties with the highest unemployment, which tend to be majority-white, GOP-leaning, and rural. But many low-income people of color who live in high-unemployment urban centers would not qualify, because the wealthier suburbs surrounding those cities pull the overall county unemployment rate below the threshold.

“This is sort of a version of racial redlining where they’re identifying communities where the work requirements will be in full effect and others where they will be left out,” George Washington University health law professor Sara Rosenbaum told TPM. “When that starts to result in racially identifiable areas, that’s where the concern increases.”

Rosenbaum and other health law experts say the waivers — already approved for Kentucky, pending for Ohio, and advancing in Michigan’s legislature — may run afoul of Title 6 of Civil Rights Act of 1964, which prohibits race-based discrimination in federal assistance programs. Under that statute, even policies that are racially neutral on their face but have a disparate impact on a particular group could be illegal.

The waiver in Kentucky, the first state to win federal approval for a Medicaid work requirement, will have the effect of exempting eight southeastern counties where the percentage of white residents is over 90 percent. The work requirements will be imposed first in Northern Kentucky, which includes counties with a higher concentration of black residents. The rules are set be enforced first in that area this July, but a federal court challenge in June could decide the fate of the program.

In Michigan, the GOP-controlled legislature is trying to pass a bill to make the 700,000 people enrolled in the state’s Medicaid expansion either work at least 29 hours per week or lose their benefits for a year. According to the state’s own numbers, 105,000 people could lose their insurance, but that burden will not be shared equally across the state.

People who live in counties with unemployment rates above 8.5 percent would be exempt, and those counties are overwhelmingly white, rural, and vote Republican. But low-income residents of color in Detroit and Flint, where the joblessness and poverty are extremely high, would not receive an exemption.

A Washington Post analysis found that while African Americans make up about 23 percent of Medicaid enrollees in Michigan, they would make up just 1.2 percent of the people eligible for an exemption. Meanwhile, 57 percent of Michigan Medicaid enrollees are white, but white residents would make up 85 percent of the population eligible for an exemption.

Ohio’s Medicaid work requirement proposal — recently submitted for federal approval — is of a similar design, and would have the same disparities between urban residents of color in Cleveland and Columbus and rural white residents in the rest of the state.

John Corlett, Ohio’s former Medicaid director and the president of Cleveland’s Center for Community Solutions, studied the 26 counties that qualify for an exemption from the proposed Medicaid work requirements and found they are, on average, 94 percent white. Meanwhile, his research found, “most of these non-exempted Ohio communities have either majority or significant African-American populations.”

“The communities most at risk under this scenario are African American, and those communities already have significantly higher rates of infant mortality, lower life expectancy, and a number of other serious health disparities,” he told TPM.

Additionally, Corlett noted, the racial divides within and among counties across the U.S. are a product of decades of racist policies, and designing the exemptions on a county-by-county basis only serves to lock in those divides.

“Our housing patterns in Ohio are influenced by a past history of institutionalized segregation, and the Medicaid waiver reinforces that instead of mitigating it,” he said. “Ohio could help mitigate the racially discriminatory impact of the waiver by exempting smaller units of government — like municipalities.”

Ohio submitted its waiver to HHS the first week of May, and the policy is now under active consideration. Michigan’s still needs approval from the governor, but the GOP legislature is pressuring him to sign it, even threatening to cut state officials’ salaries if he fails to do so.

Leonardo Cuello with the National Health Law Program, one of the groups bringing the federal lawsuit on behalf of Kentucky residents, told TPM that while the exemptions in these states are aimed at addressing a genuine problem — the lack of work opportunities in many areas — they are impossible to extricate from the racialized national conversation about federal assistance and work.

“We’re talking about a policy based on stereotypes about Medicaid enrollees,” Cuello added, pointing to research that most non-elderly, non-disabled Medicaid recipients already work. “There is a constant dog whistle in the background here about making lazy people get off their couches and go to work, and playing into stereotypes about African Americans. It’s almost impossible to argue that the policy is not racial.”

Complicating the arguments playing out in several states over carve-outs for certain Medicaid recipients is the Trump administration’s ongoing internal battle over exemptions Native Americans.

As some HHS continue to insist that exempting tribal citizens from the work requirements would be an illegal racial preference, legal experts and members of Congress warn that imposing the requirements on tribal communities violates their sovereignty.