Longtime Washington denizens recognize that Congress and the president enacting a bill into law does not end the policymaking process — far from it. Enactment stands not as the end of the process, nor even the beginning of the end, but rather (to borrow from Churchill) the end of the beginning. Federal agencies must then translate statutory language into federal regulation.
To that end, the Centers for Medicare and Medicaid Services (CMS) released its rule implementing Medicaid work requirements from last year’s budget reconciliation measure on June 1, as required by that law. Because the work requirements take effect on Jan. 1, and state Medicaid programs need clear “rules of the road” before that date, Congress specified that the interim final rule will take effect before CMS can respond to public comments. However, the public can still submit comments between now and July 31, and CMS will consider those comments when drafting the final regulation.
The rule generated immediate and predictable objections from leftist groups, many of whom opposed enacting work requirements in the first place. But a closer examination of the provisions of the rule, and the statute it implements, shows the reasonable nature of asking able-bodied adults — the requirements only apply to those individuals in Obamacare’s Medicaid expansion — to work in exchange for receiving taxpayer-funded benefits.
Less Than Meets the Eye
Most people think a Medicaid work requirement linked to 80 hours of community engagement per month applies year-round. But as I previously noted, the vast majority of states replying to a Kaiser Family Foundation survey this spring said they would check beneficiaries’ compliance with work requirements every six months, and only for one month out of every six:
- A total of 34 states said they will conduct checks every six months. Only Indiana and New Hampshire will check compliance quarterly, while Idaho, Iowa, Kentucky, Michigan, New Mexico, North Dakota, and West Virginia had yet to decide.
- Additionally, 34 states said that when processing renewal applications, they will look back one month to check compliance with the work requirement. Again, only Indiana and New Hampshire will look back for a full three months, while Arizona, Idaho, Iowa, Kentucky, North Dakota, and West Virginia had yet to decide.
Only in Indiana and New Hampshire, which will verify compliance every quarter and with a three-month lookback period, will Medicaid beneficiaries have to document work, education, or volunteering 80 hours per month every single month. Most states will check beneficiaries’ compliance for two months out of the year, meaning beneficiaries can meet the work requirement by working 80 hours per month in only two months — just 160 hours per year.
Additional Flexibility
In the rule, CMS provided numerous ways beneficiaries can demonstrate compliance with community engagement. For instance, the rule’s definition of work includes unpaid work or work done for barter (e.g., performing tasks in exchange for other goods and services rather than cash).
The law also excludes beneficiaries with a substance use disorder from the work requirement. The rule said this exclusion applies to all those with substance use disorders, except those in “stable recovery,” defined as “individuals … [who] have been in recovery for 5 years or longer.” In other words, individuals diagnosed with a substance use disorder will likely be excluded from the work requirements for at least five years, and CMS made clear that this exclusion is “not limited to individuals in an active treatment program.”
Left’s Objections
Given the flexible ways to meet the work requirement, one remaining objection might come from its implementation and the (reasonable enough) concern that people might get lost in the shuffle — that is, they actually worked but had issues submitting the relevant documentation. The rule addresses these concerns by spelling out how states must use existing databases as much as possible to demonstrate compliance — for instance, by verifying college attendance using university databases or using existing data to confirm a veteran with a total disability (also excluded from the requirement). CMS took pains to emphasize that asking beneficiaries for information and documentation should be Medicaid programs’ last resort, not the first option.
Upon the rule’s release, the welfare-industrial complex objected to CMS’s definition of medical frailty and limits imposed on self-attestation of conditions beginning in January 2028, after a one-year transition as work requirements launch. But the definition of medical frailty also includes the expansive definition of substance use disorder described above, which looks so wide as to leave the door open for abuse.
Moreover, given the well-documented instances of fraud on the Obamacare Exchanges, unchecked self-certification (i.e., the “honor system”) was never going to happen under this administration — and should not happen under any administration. Even after the requirement takes full effect in January 2028, beneficiaries will still be able to self-certify their medical condition once and then will have to submit documentation when their condition comes up for review 12 months later. Giving people a full year to find a doctor who can document their condition seems far from draconian.
Democrats will object, not least because they believe it’s in their political interests to object. But the work requirement rule sets reasonable, perhaps too reasonable, parameters. Federal law should encourage able-bodied adults receiving taxpayer-funded benefits to contribute to the community while advancing their own self-sufficiency, and the CMS rule does just that.
