New federal Medicaid rules require 1 month of work. Some states demand more.

The millions of people who apply for Medicaid in the coming years will have to prove they have been working, going to school or volunteering for at least a month before they can get or maintain health insurance through the government program.

But Republican lawmakers in some states say new rules – part of the GOP Act on a big and beautiful bill, sign last July by President Trump – does not go far enough.

Indiana is leading this charge, with a new law that requires applicants to prove they have worked or participated in a similar activity for three consecutive months to qualify for benefits.

Meanwhile, residents of many other states will have to prove they have only been working for a month, the least burdensome option under Mr. Trump’s tax and domestic spending law. He instructs states to decide whether to require one, two or three months of work history.

As in Indiana, Republican lawmakers in Idaho also approved a three-month requirement, and the state’s governor signed the bill on April 10.

These efforts, along with similar measures in Arizona, Missouri and Kentucky, aim to restrict the flexibility needed to implement federal law at the state level.

“Normally, you wouldn’t see state legislators weighing in on these decisions,” said Lucy Dagneau, a senior official in the advocacy arm of the American Cancer Society.

The nonpartisan Congressional Budget Office estimates that 18.5 million adults will be subject to the new rules, which will be applied in 42 states and the District of Columbia. In Indiana, work rules will target about 33 percent of the state’s Medicaid population. The rules generally do not apply to children, people 65 or older, or people with disabilities or serious health problems.

Typically, it is state administrators – not lawmakers – who detail how they plan to comply with new federal standards, and often look to federal regulators for guidance. But officials at the Centers for Medicare & Medicaid Services have yet to tell states how to comply with many aspects of the sweeping budget law, leaving state lawmakers to intervene.

Gov. Mike Braun, a Republican, signed Indiana’s bill on March 4, making his state the first to set the Medicaid work requirement at three months — the longest period allowed under federal law.

Republican Sen. Chris Garten introduced a bill in January saying it was necessary to “align” state law with new federal Medicaid rules. He also presented the bill as a way to combat “waste, fraud and abuse” in public programs.

When ineligible people are enrolled, it deprives “really vulnerable Hoosiers who really need help,” Garten said at a committee hearing in January.

Democratic Sen. Fady Qaddoura expressed skepticism during the hearing and questioned the need for the legislation. Qaddoura asked Indiana Family and Human Services Administration Secretary Mitch Roob to provide an estimate of the number of ineligible people enrolled in Medicaid in the state.

“I think very little,” Roob replied. “There will never be any.”

After hearing Roob’s response, Qaddoura said there was no evidence of a widespread problem in Indiana. He accused Republicans of using waste, fraud and abuse as justification to deny health benefits and food assistance to vulnerable Hoosiers.

Garten then called Qaddoura’s accusation a “fundamental misinterpretation” of the bill.

Republicans have said imposing these limits protects the longevity of the Medicaid program.

“We believe in a safety net for our most vulnerable, not a hammock for able-bodied adults who choose not to work,” Garten said. “By tightening these screws, we ensure that our safety net remains durable.”

Medicaid enrollment in Indiana is expected to decline as a result of Garten’s legislation, according to an analysis by the nonpartisan Indiana Legislative Services Agency.

Medicaid helps people stay healthy so they can continue to work, said Adam Mueller, executive director of the Indiana Justice Project, a nonpartisan legal advocacy organization focused on health, housing and food insecurity.

Mueller is concerned that people will have difficulty proving their work history, especially those in non-traditional jobs.

“If the goal is to get people involved, a month is enough,” Mueller said.

Ultimately, he fears the law will harm Hoosiers who need help the most. “They’re going to get trapped by bureaucratic hurdles.”

An analysis from the Center on Budget and Policy Priorities predicts that the work rules will impose new barriers to coverage and that how states choose to implement the rules “will significantly affect the number of people who lose coverage.” State policy decisions will determine “the extent of the burden,” the left-leaning think tank believes, and opting for a shorter look-back period “will allow more people to register.”

Lawmakers in several states have considered limits. And the same right-wing lobbying group, the Foundation for Government Accountability, testified in favor of these measures in Arizona, Indiana and Missouri.

In Missouri, FGA lobbyist James Harris said the measure aims to “lift people out of addiction and restore dignity and pride in work.”

Missouri State Rep. Darin Chappell proposed requiring a three-month lookback period, as is the case in Indiana. But the latest version of the bill he sponsored would require applicants to prove they’ve worked for just one month before registering.

Chappell, a Republican, said his initiative would encourage a “work mindset.”

Anna Meyer, owner of a small bakery in Columbia, Mo., said that implies she and other Medicaid recipients are lazy. “I’ve been working since I was 15,” she says. “I’m 43 now.”

Meyer, who voiced opposition, said she has previously had problems submitting information to the state Medicaid agency. She worries the new reporting requirements could put her and others at risk of losing their coverage, even if they follow work rules.

She suffers from fibromyalgia, a chronic condition that increases overall sensitivity to pain. She also suffers from food allergies. Medicaid helps pay for the medications and doctor visits that keep her healthy and allow her to continue working.

“I work really hard,” Meyer said.

In St. Louis, Jessica Norton, an obstetrician-gynecologist, treats many Medicaid patients at an Affinia Healthcare clinic. She said they struggle to stay insured even though Missouri extends a full year of Medicaid coverage to eligible women after they give birth. Some of his patients are inexplicably excluded from this coverage at the time of their examination, six weeks after birth. She worries that red tape related to new work requirements will make it harder to maintain insurance, even though pregnant women and new mothers are supposed to be exempt.

Norton criticized lawmakers for the message the policy sends to vulnerable patients. They say, ‘Oh, actually, health care is a privilege and you have to earn it,'” she said.

Nearly two-thirds of adults ages 19 to 64 on Medicaid already work, according to KFF. The reason most remaining adults on Medicaid aren’t working is because they’re retired, serving as caregivers or too sick, KFF found.

Some states not only impose the strictest requirements, but also block optional leniency built into federal rules.

For example, states can adopt additional exemptions to the work rules, such as allowing people to claim a “short-term hardship,” designed to provide continued Medicaid coverage to people with health conditions that prevent them from working.

Missouri lawmakers are seeking a constitutional amendment to prohibit their state from offering such optional exemptions. But patient advocates warn that these limits would hurt the state’s vulnerable residents when they need coverage most, particularly cancer patients in rural Missouri.

Often, patients in rural Missouri must travel to Kansas City or St. Louis for treatment, disrupting their ability to work, Emily Kalmer, a lobbyist for the advocacy arm of the American Cancer Society, testified at the January hearing. Recognizing this, federal law provides certain exemptions for this type of scenario.

But this short-term hardship exemption would not be possible in Missouri.

Time is “very important in the life of a cancer patient or cancer survivor,” Kalmer said.

KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of the major operating programs of KFF — the independent source for health policy research, polling and journalism.