Policy makers on the right applauded the move. But there was a consequence. Medicaid expansion in Indiana did give approximately 240,000 new people coverage, but in the years since it was implemented, portions of those eligible for benefits have been unable to pay their premiums. From 2015 to 2017, about 25,000 people in Indiana lost access to Medicaid.

In 2017, in her new position as CMS administrator, Verma gained the power to influence how every state administered its Medicaid programs.

In January 2018, for the first time since Medicaid’s creation, in 1965, Verma’s CMS gave permission to a state government to require certain citizens to work in order to keep benefits. The state was Kentucky, which planned to launch a work-requirement program this year. Details about who exactly would be subject to the requirement are still being ironed out. But according to Kentucky state officials’ estimates, at least 95,000 people would lose Medicaid coverage over a five-year period.

Then, in March, Arkansas received permission to introduce a work requirement—and Arkansas was faster out of the starting gate, inaugurating its effort in phases. Beginning last June, people on Medicaid in Arkansas ages 30 to 49 who earned at or below the poverty line had to find work or participate in activities such as volunteering or job training to continue receiving Medicaid benefits. Certain people were exempt, such as those who were medically frail or who had a dependent child. From June to December, more than 18,000 people lost coverage in Arkansas as a result of the new policy, according to the Arkansas Department of Human Services.

Medicaid advocates have not been quiet. Both HHS and CMS, along with Verma and Alex Azar II—who took over as HHS secretary after Price resigned following a scandal involving his use of chartered jets and military aircraft—were immediately the target of lawsuits seeking to overturn the work requirements. They were filed in the U.S. District Court for the District of Columbia on behalf of people in Arkansas and Kentucky, as well as those in New Hampshire, whose work-requirement mandate has just gone into effect.

The plaintiffs allege that work requirements contradict one of the two chief stated objectives of Medicaid, as laid out in the 1965 Social Security Act Amendments: to “furnish medical assistance on behalf of families with dependent children and of aged, blind, or disabled individuals, whose income and resources are insufficient to meet the costs of necessary medical services.”

For its part, the Trump administration argues that work requirements further the second objective of Medicaid: to provide “rehabilitation and other services to help such families and individuals attain or retain capability for independence or self-care.” Verma and others maintain, in effect, that employment should be considered a form of rehabilitation that leads to financial independence.