What the Trump Administration’s New Executive Order on Work Requirements Means for Medicaid

In the midst of a busy day on Capitol Hill yesterday, President Trump signed a long-anticipated Executive Order (EO) entitled, “Reducing Poverty in America by Promoting Opportunity and Economic Mobility.” Notably, the EO directs various Federal agencies (including the Department of Health and Human Services) to review existing guidelines on publish assistance programs to ensure they are in line with the President’s outlined “Principles of Economic Mobility.” These principles include, among other policy goals, the introduction and/or strengthening of work requirements in various public assistance programs (including Medicaid.)

For those of you who have been following this blog (or Medicaid policy generally) over the last few months – you may be scratching your heads. Hasn’t the Trump Administration already both signaled its intent, and even fulfilled its promise in part, to introduce work requirements in the Medicaid program? Wasn’t this the entire purpose of the January 11, 2018 State Medicaid Director letter issued by then-Director of CMCS Brian Neale?

Yes and no.

Yes — the Trump Administration has already signaled its commitment to introduce work requirements into the Medicaid program, and has even approved three waivers incorporating work requirements (KY, IN, and AR) with seven more pending approval. But the context of the EO is much more far-reaching, extending beyond Medicaid to other Federal and state public assistance programs, including SNAP and TANF. Moreover, from the EO we can gleam some additional insights into the Trump Administrations’ thinking:

  • It is clear the Trump Administration is gearing up for a legal battle. While the issuance of an Executive Order really does not add any legal heft to the ongoing legal arguments about the permissibility of work requirements in the Medicaid program, it may be used as additional evidence as to the “objectives” of the Medicaid program, a key legal fact in whether or not a waiver can be approved under section 1115 of the Social Security Act.
  • It is also clear that the Trump Administration takes an expansive view of what constitutes “work.” The EO defines work to include, “unsubsidized employment, subsidized employment, job training, apprenticeships, career and technical education training, job searches, basic education, education directly related to current or future employment, and workfare.” This expansive definition may appease some Democrat-led states that are currently examining the introduction of work requirements in their Medicaid programs.

As Medicaid scholars continue to point out, most non-Elderly adult Medicaid enrollees already work. And for those not working, we know that there are typically very good, documented reasons for this (school attendance, caregiver duties, non-document disabilities.) The question then becomes – what is the true impact of the EO?

The answer of this is yet to be seen. The Trump Administration has given Federal agencies 90 days to submit regulatory proposals to OMB on how to reform their existing guidance to align with the new work-oriented principles. We will be watching closely to see if CMS issues any additional guidance on this topic, and also how changes in other public assistance programs may have impacts (whether intended or not) in the Medicaid program.



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