The big news last week, you will recall, was the Trump administration opening the floodgates for states to impose work requirements in the Medicaid program, and Kentucky becoming the first state to get federal approval for such a mandate.

The work requirement is the headline, so to speak, out of Kentucky. But Republican Gov. Matt Bevin — who took over in 2015 for outgoing Democratic Gov. Steve Beshear, who had made the Bluegrass State one of Obamacare’s success stories — has a whole lot more up his sleeve.

Aside from the work requirement, which mandates 20 hours of employment-related activities per week to maintain coverage, Bevin had proposed — and the Trump administration has now approved — the following changes to Kentucky’s Medicaid program:

Imposing premiums, which increase based on income: from $1 a month for people making $3,000 a year or less up to $15 a month for a person making $12,000 a year

Six-month lockouts: If a person making between $12,000 and $15,000 fails to pay their premium, they can lose their coverage and are not allowed to re-enroll for six months; if a person fails to re-enroll during a new open enrollment period, they would also be locked out of coverage for six months unless they complete a financial or health literacy class

Non-emergency medical transportation would no longer be covered for the Medicaid expansion population

The Kentucky waiver crosses several red lines that the Obama administration previously refused to approve but the Trump administration will. One is the work requirement. Another is the possibility of penalizing people in poverty for failing to pay a premium. (They can be forced to wait two months for their coverage to start.) And a third is locking people out of coverage for a failure to comply with the state’s new requirements.

Using the state’s own coverage and budget estimates, Georgetown University’s Center for Children and Families projected that, in five years, Kentucky’s waiver would eliminate health coverage for 100,000 low-income people in the state.

This will create a dramatically more conservative and, more importantly, smaller Medicaid program in Kentucky. Medicaid expansion has covered an estimated 500,000 people in or nearly in poverty in the state, which saw the most dramatic drop in its uninsured rate under the Affordable Care Act of any state.

”These decreases in coverage are anticipated as a result of beneficiary non-compliance with waiver policies, such as premium payments and employment requirements,” the nonpartisan Kaiser Family Foundation wrote in its analysis of the waiver’s effects in its first few years.

This is the new, more restrictive Medicaid program that the Trump administration and Republican-led states could create over the next few years. Work requirements, yes, but also premiums for people who don’t have much income to spare and steep penalties for non-compliance.

If they become widespread, the result, based on these Kentucky estimates, could be hundreds of thousands — or even millions — of poorer Americans losing health coverage.

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