WASHINGTON — The Trump administration said on Thursday that it would allow states to impose work requirements in Medicaid, a major policy shift that moves toward fulfilling a conservative vision for one of the nation’s largest social insurance programs for low-income people.
Federal officials said they would support state efforts to require able-bodied adults to work or participate in other “community engagement activities” as a condition of eligibility for Medicaid.
“Our fundamental goal is to make a positive and lasting difference in the health and wellness of our beneficiaries, and today’s announcement is a step in that direction,” said Seema Verma, the administrator of the federal Centers for Medicare and Medicaid Services.
Ms. Verma said the Trump administration was responding to requests from Medicaid officials in 10 states that wanted to run demonstration projects testing requirements for work or other types of community engagement like training, education, job search, volunteer activities and caregiving.
Under the new policy, Trump administration officials would allow work requirements in Medicaid somewhat similar to those already imposed in other programs like food stamps, now known as the Supplemental Nutrition Assistance Program, and the welfare program known as Temporary Assistance for Needy Families.
In a speech to state Medicaid officials in November, Ms. Verma indicated that the Trump administration would be receptive to work requirements and other conservative policy ideas to reshape Medicaid. And she criticized the Obama administration, saying it had focused on increasing Medicaid enrollment rather than helping people move out of poverty and into jobs.
“Believing that community engagement requirements do not support or promote the objectives of Medicaid is a tragic example of the soft bigotry of low expectations consistently espoused by the prior administration,” Ms. Verma said. “Those days are over.”
The Medicaid proposals came from Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Several other states are considering work requirements.
In one state, Kentucky, the waiver application seeks to require most non-disabled Medicaid beneficiaries age 19 to 64 to work at least 20 hours a week. They could meet the requirement through not just paid employment, but also volunteer work, job training, searching for a job, going to school or taking care of someone elderly or disabled.
Pregnant women, full-time students and primary caretakers of children under 19 or disabled adult dependents would be exempt from the state’s work requirement, as would people deemed medically frail.
Advocates for Medicaid beneficiaries said the new policy was likely to be challenged in court if people were denied coverage for failure to meet a state’s work requirement.
Federal law gives the secretary of health and human services broad authority to grant waivers for state demonstration projects that “promote the objectives’’ of the Medicaid program. In the past, federal officials said that work was not among those objectives.
But Trump administration officials said on Thursday that work requirements were consistent with the goals of Medicaid, because work and work-related activities could improve the health of Medicaid beneficiaries.
“Productive work and community engagement may improve health outcomes,” Brian Neale, the director of the federal Medicaid office, said on Thursday in a letter to state Medicaid directors. “For example, higher earnings are positively correlated with longer life span.”
In addition, Mr. Neale said, researchers have found “strong evidence that unemployment is generally harmful to health,” while employment tends to improve “general mental health.”
Medicaid beneficiaries could work at a variety of jobs — as cashiers, telemarketers, housekeepers, nursing and home health aides, child care providers, cooks and dishwashers, waiters and waitresses, retail sales clerks, landscapers, security guards and construction laborers, for example. They could also work as volunteers at food pantries and other charitable organizations.
The Trump administration said that states imposing work requirements must have plans to help people meet those requirements and should help arrange job training, child care and transportation as needed. But, it said, states cannot use federal Medicaid funds to pay for such “supportive services.”
President Trump’s approval rating fell across many demographic groups over his first year in office, including among those seen as important to his base.
Medicaid has a major role in combating the opioid epidemic, paying for a wide range of treatments and medications. But people addicted to opioids are often unable to work or to find jobs, and some employers are reluctant to hire people who fail drug tests.
Ms. Verma said the Trump administration would require states to make “reasonable modifications” of their work requirements for people who are addicted to opioids or have other substance use disorders.
For example, she said, time spent in medical treatment for opioid addiction might be counted toward compliance with a state’s work requirement. Alternatively, she said, states could exempt people from the work requirement if they were participating in “intensive medical treatment” for addiction.
The Trump administration said that state Medicaid officials could not impose work requirements on pregnant women, elderly beneficiaries, children or people who were unable to work because of a disability. States must also create exemptions for people who are “medically frail.”
Despite such exemptions, Democrats called the new policy inhumane, meanspirited and malicious, echoing criticism of work requirements in a welfare law adopted in 1996.
Representative Frank Pallone Jr. of New Jersey, the senior Democrat on the House Energy and Commerce Committee, said that “the Trump administration’s action today is cruel and a clear violation of both the Medicaid statute and longstanding congressional intent” for waivers, which he said were meant to “allow states to expand access to Medicaid, not restrict it.”
Brad Woodhouse, the campaign director of Protect Our Care, an advocacy group that supports the Affordable Care Act, said the new policy was “the latest salvo of the Trump administration’s war on health care.”
“A majority of adults covered by Medicaid who can work, do work — often two or three jobs in fields like the service industry that are less likely to offer insurance,” Mr. Woodhouse said.
Advocates for Medicaid beneficiaries said that work requirements would harm some people who are unemployed, making it more difficult for them to obtain the health care they need.
“There are strong reasons to believe that work requirements will reduce access to health care and thereby make it harder for some people to work,” said Hannah Katch, a policy analyst at the liberal-leaning Center on Budget and Policy Priorities.
But the new policy is exactly what some Republican governors were seeking.
In his State of the State address on Tuesday, Gov. Phil Bryant of Mississippi, a Republican, said he supported a “work force requirement” for able-bodied adults on Medicaid.
“This is not, as some would have you believe, a punitive action aimed at recipients,” Mr. Bryant said. “It will actually help this population reap the rewards of a good job, and one day receive health care coverage from their employer, not the state or federal government.”
Gov. Dennis Daugaard of South Dakota, a Republican, said he would seek a waiver for a work requirement that could affect 4,500 people.
“Work is an important part of personal fulfillment,” Mr. Daugaard said. “There’s a sense of pride that comes with having a job to do and being able to provide for your family.”
Mr. Neale, the federal Medicaid official, acknowledged that the support for work requirements was “a shift from prior agency policy,” but he said that such requirements could “promote the objectives of Medicaid.”
People who meet the work requirements of the food stamp program and Temporary Assistance for Needy Families “must automatically be considered to be complying with the Medicaid work requirements,” Mr. Neale said.
The federal government and states generally share the cost of Medicaid and could save money if enrollment goes down because of work requirements. White House officials say Medicaid spending is growing at an unsustainable rate, and last year President Trump supported bills that would have cut hundreds of billions of dollars from projected Medicaid spending over 10 years.
More than 70 million Americans are enrolled in Medicaid, and the federal government spent more than $350 billion on the program in the last fiscal year, the Congressional Budget Office says.
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