The Trump administration issued guidance to states early Thursday that will allow them to compel people to work or prepare for jobs in order to receive Medicaid for the first time in the half-century history of this pillar of the nation’s social safety net.
The letter to state Medicaid directors opens the door for states to cut off Medicaid benefits to Americans unless they have a job, are in school, are a caregiver, volunteer or participate in other approved forms of “community engagement” — an idea that some states had broached over the past several years but that the Obama administration had consistently rebuffed.
The new policy comes as 10 states are already lined up, waiting for federal permission to impose work requirements on able-bodied adults in the program. Three other states are contemplating them. Health officials could approve the first waiver — probably for Kentucky — as soon as Friday, according to two people with knowledge of the process.
The guidance represents a fundamental and much-disputed recalibration of the compact between the government and poor Americans for whom Medicaid coverage provides a crucial pathway to health care.
But most health policy experts, including a few noted conservatives, have regarded the government insurance enabling millions of people to afford medical care as a right that should not hinge on individuals’ compliance with other rules.
On a related note, this came up again in yesterday’s thread but the Medicaid holding in Sebelius is mentioned far too little in discussions of the worst Roberts Court rulings. Roberts’s inept re-writing of the statute is quite literally killing thousands of people a year, while imposing major health and/or financial burdens on many others. It strikes me that if the consequences of a decision are going to
be this dire it had better be compelled by black-letter law. But of course this neoconfederate holding is not compelled by any explicit constitutional text; at best it’s an indirect structural inference. The leading precedent upheld the use of the federal spending power in a case in which the relationship between the conditions and the overall purpose of the spending was much more oblique. And the kicker is that the holding doesn’t even meaningfully protect the Sovereign Dignitude of the states going forward, since it can be easily evaded by formally enacting new programs rather than formally modifying existing ones, or (as Ginsburg observed in her unanswerable dissent) by federalizing programs rather than giving states a role. So it’s a massively incoherent decision that was not compelled by the text of the Constitution, is a major stretch of existing doctrine that Congress could not have reasonably anticipated, has resulted in huge human costs, and doesn’t even meaningfully protect the interests it claims to be protecting. Heckuva job!