The Trump administration is facing a key test with Mississippi’s Medicaid program as the state seeks permission to be the first ever to impose work requirements without expanding Medicaid under ObamaCare.

Already one of the poorest states in the nation, advocates say work requirements for “able-bodied” beneficiaries could decimate the health coverage that tens of thousands of residents depend on.

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While the administration touts state flexibility and has already approved work requirements in Medicaid expansion states, there could be far reaching practical and political consequences for approving them in Mississippi.

“If the objective of work requirements is to lift people out of poverty, it’s hard to make that case when the income levels are so low,” said Patricia Boozang, senior managing director for consulting firm Manatt Health.

Mississippi first submitted its application in January, shortly after the Trump administration encouraged states to seek work requirements.

The five-year waiver request from Republican Gov. Phil Bryant seeks to require non-disabled adults to participate in at least 20 hours per week of “workforce training.”

To be eligible, Medicaid beneficiaries must work, be self-employed, volunteer or be in a drug treatment program, among other approved activities. If people don’t comply, they’ll lose their Medicaid coverage.

Mississippi was still waiting to hear from the administration when the state made changes to their request, re-opening a federal comment period in July. That comment period closed Aug. 18, and advocates point to the changes submitted by the state as a sign that the administration wants to green light the request.

“They’re trying to strengthen their hand by getting more public comments,” said Joan Alker, executive director of the Georgetown University Center for Children and Families (CCF). “So that worries me they are trying to get to yes.”

The Mississippi Division of Medicaid did not respond to a request for comment.

Mississippi made changes to attempt to solve a major problem related to its strict Medicaid eligibility requirements. In order to be covered, a single parent has to earn less than $3,300 a year. For a family of three, it’s less than $6,000 a year.

If those individuals are required to work, they’ll likely earn too much to qualify for Medicaid, even though the jobs likely won’t offer insurance. It’s a Catch-22 that the administration is keenly aware of.

Seema Verma, administrator of the Centers for Medicare and Medicaid Services, said during a news briefing in May that the administration would need to work with nonexpansion states to ensure Medicaid beneficiaries would not be at risk of losing coverage.

States "need to come up with a plan to address this issue,” said Verma, who has never ruled out approving a nonexpansion waiver. "We're dealing with a vulnerable population, so we want to be careful."

Mississippi acknowledged those concerns, and its changes included a two-year transition period available for people who comply with the work requirements but fall into that coverage gap scenario.

The state also removed language related to its desire to save money.

Roy Mitchell, executive director of the Mississippi Health Advocacy Program, said he expects the administration to approve the waiver, adding that his organization is preparing to help people who will lose coverage.

“We have a consumer assistance program to help people who were denied Medicaid eligibility,” he said. “We anticipate a lot of people falling through the cracks.”

The Trump administration has made state flexibility a priority, approving work requirements in Arkansas, New Hampshire and Kentucky. But there could be broader consequences for approving them in Mississippi.

In a letter to Health and Human Services Secretary Alex Azar, a group of 12 Democratic House members, led by Mississippi’s Rep. Bennie Thompson Bennie Gordon ThompsonHouse panel pans ICE detention medical care, oversight Senate to hold nomination hearing for Wolf next week Hillicon Valley: FBI chief says Russia is trying to interfere in election to undermine Biden | Treasury Dept. sanctions Iranian government-backed hackers MORE, warned that the work requirements would disproportionately hit African-American families the hardest.

“If approved, the state’s plan would have the effect of eliminating Medicaid coverage as it currently exists for the poorest parents (mostly mothers) in the state of Mississippi,” the lawmakers wrote.

Thompson and the other members urged Azar to reject the request.

Mitchell said if the waiver is approved, “all eyes will be on Mississippi.”

“The Trump administration will own this, they won’t be able to walk away from this,” he said. “You’ll have really heart wrenching stories of people who lost Medicaid.”

“This will be a measuring stick for the Trump administration in terms of its health policy,” he added.

Joe Antos, a health care expert at the right-leaning American Enterprise Institute, said he doesn’t think the administration will approve the waiver. He said officials won’t want the optics of poor parents being kicked off Medicaid.

If the administration does approve the request, Antos said it could give ammunition to Democrats, especially if they take control of the House and Senate after the November midterm elections.

He said Azar and Verma “would be testifying 24 hours a day on this issue,” and that the “wise political move” is to wait until after the midterms so it’s “not biasing the vote.”

“It would be nuts to take action now,” he said.