The Trump administration has reportedly turned its attention to another critical aspect of Medicaid, the government health insurance program for low-income people: Its guarantee of lifetime coverage. The same federal waiver requests that allowed the states of Kentucky and Indiana to end Medicaid coverage for able-bodied enrollees (for which 10 additional states have reportedly now applied) could also impose time limits on Medicaid coverage.

Five states — Arizona, Kansas, Utah, Maine and Wisconsin — are requesting federal waivers that will permit time limits on lifetime Medicaid enrollees, according to a McClatchy DC report. The Department of Health and Human Services did not respond to a request for comment, according to the report.

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According to McClatchy DC, Arizona and Utah both requested a five-year limit. In Utah, the limit would only apply to adults without children, and Medicaid coverage would be provided on the “expectation” that recipients would “do everything they can to help themselves before they lose coverage.” Wisconsin reportedly requested to limit coverage for adults without children to four years, and Kansas reportedly requested a limit of three years. In Utah, Wisconsin and Kansas, the requested time limits would reportedly be applicable to enrollees who meet each state’s work requirements — in effect, altering the essential function and purpose of Medicaid with no legislative mandate to do so.

It is noteworthy that three of the states that have reportedly applied to impose limits on lifetime coverage -- Arizona, Maine and Wisconsin -- are key purple states likely to be electoral battlegrounds. Under the proposal in Maine, enrollees who don’t meet state work requirements could potentially only receive three months of Medicaid coverage.

If approved in any of the states, people with health issues that hinder their ability to work would be greatly affected, as would people who work full-time jobs without employer-provided health insurance. These changes could negatively affect a large aging population and could also push more sick people without coverage into emergency rooms, according to the McClatchy report. Under the Emergency Medical Treatment and Active Labor Act, hospitals are still required to see patients who need emergency medical care, regardless of insurance coverage or a patient’s ability to pay.

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Many advocates strongly oppose the move, including Andy Slavitt, a former acting administrator of the Centers for Medicare and Medicaid Services under the Obama administration from 2015 to 2017.

“This would be the wrong direction for our country and millions of Americans,” Slavitt said on Twitter.

Gail Wilensky, who ran Medicaid from 1990 to 1992 under President George H.W. Bush, told McClatchy DC the proposed move struck her as “cruel and inappropriate.”

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The Trump administration is positioning this proposed change, however, as a way to give states more “flexibility” in their administration of the Medicaid program. Seema Verma, a current administrator at the Centers for Medicare and Medicaid Services, published an op-ed in The Washington Post this week describing the Trump administration’s strategy to put more power over these programs under state control:

Our aim is to restore a strong state-federal relationship while also modernizing the program to deliver better outcomes for all the populations served. The first step is to recognize that Washington does not know what is best for states. To the contrary, we should empower states to work with their communities, providers and citizens to design innovative programs that meet their diverse needs, while holding them accountable for achieving positive outcomes.

Some observers have noted that these "Section 1332 waivers" affecting Medicaid delivery are more powerful than they appear. They could even serve as a loophole for the Trump administration to further dismantle the Affordable Care Act. A recent report from the Brookings Institution explained that former Health and Human Services Secretary Tom Price had framed the administration’s approach to Section 1332 waivers "as a key part of its strategy to address the problems it associates with the ACA. This waiver process, then, may be an opportunity for Republicans to claim credit for reforming health care, even if that change does not ultimately come through the legislative process.”

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According to September 2017 reporting, nearly 5.7 million Americans are covered by Medicaid in the states now seeking to impose time limit restrictions. It’s unclear how many of those people would fail to meet the proposed work requirements and could lose coverage. In any case, this proposed move echoes a running theme of the Trump administration: There is a sharp line drawn between those who "deserve" help and those who do not. If you're not conspicuously contributing to the economy, regardless of your circumstances, you don’t count.