In some conservative states still without Medicaid expansion, lawmakers’ deliberation over work requirements will be critical to their ultimate decision. For example, the Utah House recently passed a bill approving a limited, eligibility-restricted Medicaid expansion with a work requirement in order to stave off pressure from a citizen-led ballot initiative that supports full expansion without any such restriction. The bill now sits before the state Senate.
Utah’s example is instructive, especially given the ongoing wave of pro-expansion ballot initiatives hitting conservative-leaning states. Maine Governor Paul LePage, a Republican, pushed back hard against an expansion initiative last fall, and even threatened not to implement the passed reform, which would have been a violation of state and federal law. Now, Maine is at the front of the queue seeking CMS approval for work requirements for its new expansion program. In the face of a petition to expand Medicaid in Nebraska, some state lawmakers have also suggested adding the restrictions. And with Idaho petitioners making headway on yet another ballot initiative, a plan to create a more limited expansion with work requirements is now circulating in the state legislature.
These states illustrate two trends. First, popular support for full expansion is growing—reflecting record-high public opinion for the ACA across the country—even among conservative voters and in conservative-leaning areas. That growing energy is manifesting in the bipartisan ballot initiatives and other campaigns that seek to circumvent GOP state legislators and governors, who often still oppose the measures. Second, facing the turning tide of public opinion, those GOP state leaders are choosing to stonewall or make expansion as restrictive as possible.
The latter course of action is gaining steam, with assistance from Verma. But the reforms, touted as maximizing states’ flexibility, have but one major outcome: They cover fewer people. The net effect of work requirements, premiums, and lockout periods will be fewer enrollees, and more people will be kicked off for failure to work or pay premiums.
With more and more states eyeing work requirements—and more conservative legislators considering them as mechanisms to get out in front of public opinion, while simultaneously constraining state programs—these reforms actually stand to short-circuit the ACA’s intent to give coverage to more people, even as they might prompt more states to get in the expansion game. Widespread eligibility restrictions could offset the benefits of providing greater access to care for low-income individuals, and set the stage for the creation of a limited, punitive Medicaid regime nationwide.
That appears to be the point. While appetite for full Obamacare repeal has died down, and CMS has recently accepted that the ACA is the law of the land, the push to tightly constrain Medicaid budgets and caseloads is only ramping up. The Trump administration’s strategy for Medicaid appears particularly Odyssean: By providing more states with the mechanisms to expand Medicaid, they also provide the ultimate tools for shrinking it.