“Believing that community engagement requirements do not support the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Verma said in a sweeping address to the National Association of Medicaid Directors. “Those days are over.”

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The speech was Verma’s most detailed public explanation of how she plans to approach Medicaid in a highly politicized era in which Republicans still hope to roll back its expansion under the Affordable Care Act as well as enact future spending cuts through their various health-care bills.

The program’s chief problems, according to Verma, include the expansion to add able-bodied adults and overall costs, which now comprise 29 percent of total state spending. She also faulted the federal government for requiring too much reporting from states and for delaying approval of states’ waiver requests to run their programs in alternative ways.

Multiple times throughout her half-hour speech, she used the phrase “card without care” to make her point that simply enrolling people in Medicaid isn’t effective if they can’t find a doctor who will accept them — an ongoing problem with the program because its reimbursements are lower than for Medicare or private coverage.

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“We fail to live up to that promise when Medicaid merely provides a card without care,” she said. “And that’s why we’re ushering in a new era for Medicaid at CMS.”

Verma stressed that she and President Trump are “deeply committed” to the program, while accusing the prior administration of quashing state innovation and undermining Medicaid’s traditional partnership between the federal and state governments.

She listed a number of ways that CMS will change its approach, by expediting state waiver requests that mirror past approvals, allowing some waivers for up to a decade and starting a “report card” that grades state programs.

Waivers are a major way the Trump administration can reshape Medicaid. A half-dozen states have applied or soon will apply to require program enrollees to get a job or do some kind of community volunteering as a condition of their coverage.

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Verma has long supported such requirements, which the Obama administration uniformly rejected, but Tuesday was the first time she explicitly promised that her agency would approve this type of waiver request.

“The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working-age, able-bodied adults does not make sense,” she said.

Some officials from states currently asking to implement work or community engagement requirements were pleased at Verma’s declaration of support, including Kentucky Medicaid commissioner Stephen Miller.

“You heard what was said today, and we’re right in sync with that,” Miller said. He said he’s expecting notification “soon” from CMS that Kentucky’s waiver request has been approved. The state is hoping to set its new requirements in motion starting the middle of 2018.

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But New York Medicaid director Jason Helgerson said it was “completely reprehensible” for Verma to use the phrase “soft bigotry” to describe Medicaid programs that don’t impose extra requirements on low-income people seeking coverage.

“Where should I start? Helgerson said, when asked to respond to Verma’s address. “Shocked, appalled would be the two primary reactions I have.”