South Carolina Is the 10th State to Impose Medicaid Work Requirements

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WASHINGTON — Although the courts have so far blocked President Trump’s attempts to impose work requirements on Medicaid recipients, his administration announced on Thursday that it would allow a 10th state, South Carolina, to condition Medicaid eligibility for many poor adults on proving that they work or engage in other activities, like volunteering.

It is the first time the Trump administration has approved such rules in a state whose working-age Medicaid population consists almost entirely of poor mothers. Unlike most of the other states that have won approval for work requirements, South Carolina chose not to expand Medicaid to most of its low-income adult population, as the Affordable Care Act had encouraged.

The approval was issued in a week when tensions between Seema Verma, the administrator of the Centers for Medicare and Medicaid, and Alex M. Azar II, the health and human services secretary, became so public and bitter that the pair was summoned to the White House to meet with Vice President Pence and warned to reconcile.

Ms. Verma traveled to Greenville, S.C., on Thursday to announce the decision with Gov. Henry McMaster, a Republican. In a statement, she predicted that the work requirements “will lift South Carolinians out of poverty by encouraging as many as possible to participate in the booming Trump economy.”

Governor McMaster echoed that sentiment: “In this economy,” he said in a statement, “there is no excuse for the able-bodied not to be working.”

Under the new South Carolina system, the state will change its Medicaid eligibility rules to allow roughly 32,000 parents with slightly higher incomes — up to the federal poverty level, which is $24,540 for a family of three — to qualify for coverage, along with roughly 80,000 parents who already do. But first they will have to prove that they meet the 80-hour a month work requirement.

As in other states, exemptions will be granted to certain people, including those who can prove that they are the primary caregiver of a child or disabled adult and those identified as medically frail.

“You’re going to have to raise your hand and report and prove you are the primary caregiver,” said Joan Alker, the executive director of the Georgetown Center for Children and Families. “So this is creating a mountain of paperwork that we know will result in huge coverage losses.”

Ms. Alker added that her organization’s research found the population subject to the new requirements is disproportionately black.

The South Carolina plan will also expand Medicaid to an estimated 14,000 adults who are chronically homeless, in need of substance abuse treatment or in the criminal justice system. But they, too, must meet the work requirement or qualify for an exemption. With the modest coverage expansions, the state and the Trump administration may be trying to insulate themselves from an eventual adverse court ruling; Judge Boasberg pointed to the coverage losses in Arkansas, and anticipated coverage losses in Kentucky, as reasons for blocking those states’ work rules.

A coalition of groups opposed to work requirements criticized South Carolina on Thursday for becoming “the first state in the nation to exclusively impose the harmful policy of work requirements on low-income parents with children.”

The coalition, which includes the American Academy of Pediatrics, the Children’s Defense Fund, the Georgetown University Center for Children and Families and the March of Dimes, said in a statement that the requirement “adds red tape burdens that will fall squarely on parents’ shoulders.”

“Children rely on healthy parents and caregivers to help them meet their health and developmental needs,” the statement went on, “and this waiver will make it harder for parents to be there for their children.”

A federal judge struck down work requirements in three of the nine other states that introduced them — Arkansas, Kentucky and New Hampshire. Only Arkansas had already put them into effect. All three states have appealed, although Kentucky’s new Democratic governor, Andy Beshear, who was sworn in this week, has said he will rescind the work rules.

Many of the six other states — Arizona, Indiana, Michigan, Ohio, Utah and Wisconsin — have voluntarily put their work requirements on hold; Indiana and Michigan have also been sued over them.

The Arkansas work rule led to more than 18,000 people there losing coverage before Judge James E. Boasberg of the Federal District Court for the District of Columbia, blocked it in March. Even many who did work had not kept up with or even learned about the reporting requirements. There, as in Kentucky and New Hampshire, Judge Boasberg ruled that federal health officials had failed to adequately consider the impact of the rules on people with Medicaid coverage.

The rules require “able-bodied” adults to report to the state every month that they have worked, searched or trained for a job, taken classes or volunteered in order to keep receiving Medicaid health coverage, which is largely free. Ms. Verma has said such activities can improve people’s health and help them “rise out of poverty and government dependence.”

Eight additional states have requested but not yet received approval to impose Medicaid work requirements. They are Alabama, Idaho, Mississippi, Montana, Oklahoma, South Dakota, Tennessee and Virginia. Virginia, however, put its request on hold after Democrats took full control of the state legislature last month.

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