With Obamacare repeal infamously shut down by Sen. John McCain, President Donald Trump can still reform Medicaid without Congress through state waivers.

Sens. John McCain (R-AZ), Susan Collins (R-ME), and Lisa Murkowski (R-AK) tanked Obamacare repeal in the Senate last week; however, Trump can still use Medicaid state waivers to make free-market reforms to the government health insurance program.

President Donald Trump could approve state waiver applications to conservative states that remain eager to curb skyrocketing Medicaid costs.

Arkansas, Indiana, Kentucky, Maine, and Wisconsin plan to require able-bodied Medicaid recipients to work, submit to drug testing, and pay monthly premiums to help lower costs through state waivers.

Maine Governor Paul LePage hopes to submit his waiver this week; other states may also apply if the Centers for Medicare and Medicaid (CMS) approves Maine’s application.

Josh Archambault, a senior fellow at the Foundation for Government Accountability, explained that absent Congressional action, “the administration may be even more proactive in engaging with states on waivers outside of those that are already planning to do so.”

Archambault added that the reforms would help “transition able-bodied enrollees into new jobs, or higher-paying jobs.” Archambault also argued that states need to reserve Medicaid for the “truly needy,” such as children and the disabled.

Seema Verma, before becoming the CMS Administrator, orchestrated Kentucky’s Medicaid waiver request. The CMS administrator also worked with then Indiana Governor Mike Pence to reform the state’s Medicaid program.

Medicaid enrollment soared since Obamacare expanded Medicaid in 2014, handing states more federal funding to expand health insurance coverage for low-income adults. Medicaid remains states’ second largest expense after education.

The House-passed American Health Care Act (AHCA) and the Senate’s Better Care Reconciliation Act (BCRA) tried to cap Medicaid spending per capita and allow states to block grant Medicaid. Without reforms coming from Congress, states such as Wisconsin can make changes that could sustain Medicaid for generations.

Wisconsin’s work requirement waiver would stipulate that citizens receiving welfare could also meet the job work requirement by volunteering, receiving vocational training, or caring for an elderly relative. Governor Scott Walker’s (R-WI) waiver would also cut off Medicaid at 48 months unless the citizen continues to work. Wisconsin Medicaid enrollees between the income ranges of $6,000 to $12,000 would have to pay an $8 monthly premium.

Wisconsin Medicaid Director Michael Heifetz revealed that the state hopes to encourage Medicaid enrollees to seek gainful employment.

Heifetz said, “The proposal is not designed to have folks leave the program except for positive reasons.”

The state Medicaid director believes that if the Trump administration were to approve the waiver, Wisconsin could save $50 million a year and experience a drop of 5,102 Medicaid enrollees over the next five years.

Governor Walker said that social safety net programs should lift people up rather than trapping them in a cycle of poverty.

“We should treat public assistance more like a trampoline than a hammock,” Walker explained.