Last week, the D.C. Circuit ruled that Arkansas’ work requirements, which condition eligibility for the state’s Medicaid program on work, enrollment in school, or volunteering, are illegal. Judge David Sentelle, a conservative Reagan appointee, wrote the unanimous 3–0 opinion.
In encouraging and then approving state applications—called section 1115 waivers—that included work requirements for states’ Medicaid program, the Trump administration made the dubious assertion that such provisions would increase work (and thus improve health outcomes).
Such an assertion is not supported by evidence. But the court did not even have to analyze whether that particular claim was made arbitrarily, because Health and Humans Services Secretary Alex Azar’s stated objective in approving the Arkansas waiver was entirely different from that of the Medicaid program, as written by Congress into the statute: expanding coverage.
As Judge Sentelle states, “The statute and the case law demonstrate that the primary objective of Medicaid is to provide access to medical care.” In other words, the Department of Health and Human Services (HHS) must only consider whether states are expanding health coverage when approving waivers.
Yet Secretary Azar did not consider the research, presented through the public comment process, that pointed to the likelihood of coverage losses. Most adults on Medicaid are already working or have barriers to work, such as illness, disability, or caregiving. Moreover, bureaucratic barriers inherent to work requirements (for example, lack of access to a computer, fluctuating work hours, or difficulties with accessing exemptions) mean that most coverage losses would be due to red tape and not actual eligibility. Indeed, in the five months that Arkansas imposed work requirements, 18,000 people lost their health coverage.
As a result, the court found that the approval was arbitrary and capricious, and thus void. Ten other states have received approval for work requirements, though many have put theirs on hold as the courts rule on the legality, and there is ongoing litigation in two more states. The ruling does not directly affect other state requirements, and the Trump administration will no doubt appeal the ruling to the Supreme Court.
Unfortunately, work requirements are just one of several other regulatory strategies the Trump administration is pursuing that, if implemented, will reduce health coverage. Last month, the Centers for Medicare and Medicaid Services (CMS) released guidance that encouraged states to apply for a waiver to block grant their Medicaid program, meaning that states would only receive a set cap of federal funding and could limit coverage and reduce access to health care services.
And in addition to several other pending work requirement waiver requests, other state officials have pursued requests, in partnership with the Trump administration, that would further limit coverage. For example, Georgia has asked HHS for authorization to block grant the federal subsidies it gives out through a separate waiver authority, another legally questionable request that could limit discounts for low and middle income residents who purchase private insurance on the exchange.
These waivers follow several years of both failed attempts and successful efforts by the Trump administration to weaken protections found in the Affordable Care Act (ACA) and reduce health coverage. It also comes at a time when the Trump administration is, in partnership with Texas and several other anti-ACA state attorneys general, pursuing litigation—based on a flawed legal theory panned by legal scholars on both the left and the right—to try and completely overturn the ACA, which would leave millions of people without health coverage.
For the past three years, the Trump administration has pursued a policy agenda that undermines health coverage, particularly for the most vulnerable Americans, and that attempts to circumvent Congress. Last week’s ruling is a welcome relief for thousands of low-income residents of Arkansas, but coverage for millions of people still hangs in the balance.