CMS Administrator Seema Verma has made it clear from the moment she took office last year that the Trump administration will approve such proposals, but requests from nearly a dozen conservative states have stalled with federal officials for months. | Evan Vucci/AP Photo Trump paves the way for states to impose Medicaid work requirements The people most likely to be affected are working-age adults who gained coverage since 2014 under Obamacare.

The Trump administration took a major step Thursday to let states establish the first-ever work requirements for Medicaid recipients.

The policy guidance is the most concrete development yet toward achieving goal of tying Medicaid benefits to employment — a long-time conservative goal that has never been permitted since the health care entitlement program for the poor was created 52 years ago.


CMS in its letter to state Medicaid directors outlined the criteria it would use to approve state employment proposals that would require able-bodied, working-age Medicaid enrollees to get a job or participate in a related activity like job training for at least 20 hours a week in order to keep their health coverage. CMS Administrator Seema Verma has made it clear from the moment she took office last year that the Trump administration will approve such proposals, but requests from nearly a dozen conservative states have stalled with federal officials for months.

Democrats and liberal advocacy groups have warned they will go to court to block work rules as soon as the first state plan — likely Kentucky, and likely very soon — is approved. They argue that Medicaid is a health care program, and adding work requirements may undermine it.

POLITICO Pulse newsletter Get the latest on the health care fight, every weekday morning — in your inbox. Email Sign Up By signing up you agree to receive email newsletters or alerts from POLITICO. You can unsubscribe at any time. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

“By allowing states to impose harmful work requirements, the Trump Administration is endangering the life support systems millions of vulnerable Americans rely on every day," said Rep. Frank Pallone, the top Democrat on the Energy and Commerce Committee.

That's not how the Trump administration sees it.

“Medicaid needs to be more flexible so that states can best address the needs of this population. Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries," Verma said in a statement Thursday.

The people most likely to be affected are working-age adults who gained coverage since 2014 under Obamacare which allowed states to cover able-bodied people just above the poverty line, who had generally been excluded from Medicaid in the past. Thirty-one states plus the District of Columbia have done so.

Verma and most Republicans who oppose Obamacare argue that the health law deviated from Medicaid’s primary mission of covering the most vulnerable people, primarily very young children and their mothers, as well as millions of disabled people and low-income older people needing long-term care.

"We see people moving off of Medicaid as a good outcome," Verma said in a call with reporters.

Most of those traditional beneficiaries won't be subject to the employment rules, which generally require enrollees to work or participate in a related activity for 20 hours per week to stay covered. CMS also specified that people with severe medical conditions who are deemed "medically frail" would be exempt.

In a nod to Medicaid's role in treating opioid addiction, the CMS letter called for "reasonable modifications" for people with substance abuse disorders. That could include counting time in treatment as work hours, or exempting those who are receiving intensive medical treatment. Critics of work requirements have said the last thing people trying to recover from addiction need is complicated new employment rules that could jeopardize their benefits.

Independent studies have shown that most Medicaid enrollees who are eligible to work already do so. According to the Kaiser Family Foundation, 60 percent of non-elderly adults covered by Medicaid in 2016 were working part- or full-time. More than a third of those not working reported that illness or disability was the primary reason.

Now that the Trump administration has issued guidance, several sources expect that federal officials will quickly approve Kentucky’s proposed work requirement, which was initially submitted a year ago. That was toward the end of the Obama administration, which strongly opposed work rules in entitlement programs.

Indiana’s waiver is also expected to be approved in short order. Other states seeking such policies include Arizona, Arkansas, Kansas, Maine, Mississippi, New Hampshire, North Carolina, Utah and Wisconsin.

Nineteen states, most with GOP governors, have not expanded their Medicaid programs. Obamacare allowed states to cover people up to 138 percent of the federal poverty line, or roughly $16,660 for an individual and $34,000 for a family of four.