WASHINGTON—Wildlife technician. Probation officer. Flower clerk at the supermarket outside town. Anything, really.

Christina Childers’s family has been poor for generations, and she isn’t picky. With a community college degree in hand and a university degree coming soon, Childers says she has been applying for more or less every decent job within three counties of tiny Campton, a rural Kentucky community with two dollar stores and not much else.

She’s had no luck yet. For that sin, she might soon lose her health insurance.

With the permission of the Trump administration, Kentucky last week became the first U.S. state to require poor people to do some form of work in exchange for continuing to get government health coverage.

No previous president has allowed states to require labour to qualify for the Medicaid program. Since its creation in 1965, Medicaid has been available to everyone, employed or unemployed, whose income is below an income threshold set by their state — in Kentucky, $16,394 per year.

Kentucky’s new rule, announced by Republican Gov. Matt Bevin, targets adults who are not “medically frail” or serving as primary caregivers for their dependants. It will require them to work 80 hours a month — or spend 80 hours volunteering, job-training, searching for a job or enrolled in school — if they want to remain covered.

At least nine other Republican-run states have asked Trump to let them impose similar rules. Though he campaigned as a protector of Medicaid and a champion of the “forgotten,” he is likely to approve.

The move to work requirements has appalled advocates for the poor and many medical professionals, who say such rules are counterproductive, cruel and possibly illegal under the federal law that established Medicaid, which makes no mention of such rules. And it has terrified many of the hundreds of thousands of Medicaid recipients who say the program is keeping them alive and financially afloat.

“I’m doing my best to pull myself from poverty, but it just seems like a punishment to be treated a freeloading parasite,” said Childers, who voted for the Democratic opponents of Trump and Bevin. “It’s like climbing up an old, rickety ladder and then Gov. Bevin thinks it’s a genius idea to light the ladder on fire to encourage faster climbing.”

Childers, 25, said she doesn’t have the money to move to a big city, to spend her time donating her labour instead of looking for work, or to get a car that would let her broaden her job-search horizons. Bevin’s rule, she said, penalizes people for circumstances they have nothing to do with.

“There is an immense lack of jobs in Eastern Kentucky. Where is everyone on Medicaid going to find work here?” she said.

Bevin’s team has suggested that he might be more lenient on Medicaid recipients in areas without good employment options, but it has not released any specifics.

The Trump administration said on Jan. 11 it will allow states to require “able-bodied” Medicaid recipients to work. (The Associated Press)

Work requirements are popular with a majority of voters, polls show, in a country with a deep-rooted skepticism toward programs perceived as handouts to the poor. Bevin and the Trump administration have described the requirements as a kind of favour to low-income people, claiming, without solid evidence, that this incentive to work will make them healthier and happier.

Kentucky is known to Democrats as one of Obamacare’s success stories. By using Obamacare to expand Medicaid in 2014, Bevin’s Democratic predecessor allowed an additional 480,000 lower-income people to get insurance. The uninsured rate has been cut by more than half.

But Bevin argues that Kentucky should feel bad about having more people on Medicaid. He is enthusiastic about an estimate that his plan would result in 95,000 fewer people on Medicaid after five years.

“I was raised by a father who said, ‘Don’t take something that is not earned,’” he told the local media. “The vast majority of able-bodied men and women, able-bodied Kentuckians, they want the dignity associated with being able to earn and have engagement in the very things they are receiving, and an opportunity not to be put in a dead-end entitlement trap but given a path forward and upward.”

Many Medicaid recipients say it is Bevin’s plan that will send them to a dead end — or to their deaths. Forced to pay their own medical bills, some would return to the kind of life — little to no preventive care, skipped prescriptions, crushing debt — that makes them less likely to be able to keep good jobs and live long lives.

“Medically frail” people will be exempted from the plan. It is not at all clear, though, who will be considered medically frail.

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Katherine Guthrie, 49, works two Lexington jobs, as a landscaper and a cashier at a health food co-op. But she has a list of serious health problems so long she laughs when reciting it — it runs from her mind to her heart to her feet — and she says she’s often in too much pain to stand up for anywhere close to 80 hours even if she could get them. She’s at 40 now.

“My main thing is: why do you have to make it so hard? Why do you have to make it so hard on poor people? We’re just trying to live,” Guthrie said.

She cried with joy when Democratic governor Steve Beshear, for whom she voted, expanded Medicaid. Now tears were coming again.

“I’ve spent the last 24 years — I’m going to try to say this without crying — not on food stamps and not on disability, with help from my parents who are my heroes, and working as much as I could wherever I could, and obviously not living the high life. And I try to be a good person. I haven’t been able to do a whole lot for society, but I try to help people and be nice to them. And I feel like I’m being punished,” she said.

Advocates say the new rules will hurt even people who are clearly frail. Research shows that adding paperwork to qualify for health programs results in eligible people dropping off the rolls. Details of Bevin’s plan remain unclear, but it currently requires each recipient to submit monthly proof that they are complying with the 80-hour requirement.

Emily Beauregard, executive director of Kentucky Voices for Health, said Kentuckians who have drug addictions, brain injuries and other debilitating problems are unlikely to obtain the exemptions they deserve if qualifying requires “jumping through a lot of hoops.”

“This bureaucracy, this red tape, this really complicated process, is where people are doing everything they’re supposed to be doing still get hurt,” she said.

The work requirement is not Bevin’s only change to Medicaid. His package of new rules also includes a new monthly charge of $1 to $15. People who miss a payment can be locked out of Medicaid for six months.

Lawsuits are likely coming soon. Bevin has issued an unusual pre-emptive threat of retaliation — saying he will terminate the entire four-year-old expansion if the courts strike down the new work requirement.

Tracy Ison, 38, works enough hours as a Louisville salesperson to keep the Medicaid coverage she got through the expansion, and her husband, who has a severe gastric disorder that leaves him unable to work, is frail enough to be exempted. But she is distressed that the whole expansion could vanish.

“I can’t afford to pay premiums, co-pays, deductibles. I couldn’t,” Ison said. “I don’t have food stamps, I don’t have welfare, I don’t have anything. There’s only food in my kitchen because of family.”

Like Childers, Guthrie and 427,000 other Kentuckians, Ison did not vote for Bevin; like them and more than 700,000 others, she did not vote for Trump. She fumes when she sees liberals on social media say Kentuckians are getting what they deserve for their electoral choices.

“Complete ignorance. What would those people say if that was your child? If I was your daughter, or my husband was your son or your sibling? Would you think the same way?” she said.

“I don’t know what the right answer is, but everybody should have health insurance. I don’t know what happened to the compassion in the United States, but it needs to be found again to make it great again.”

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