ADEA State Update

Medicaid Expansion and Work Requirements—An Update

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MedicaidStethA total of 31 states and the District of Columbia have expanded their Medicaid programs under the Affordable Care Act since 2010. Below is a brief Medicaid expansion update for the following states: Kansas, Kentucky, Indiana, Tennessee and Virginia.

  • Kansas

On March 30, Gov. Sam Brownback (R-KS) vetoed HB 2044. The bill would have expanded Medicaid in the state in accordance with the Affordable Care Act.

Specifically, the bill modified the eligibility requirements for the Kansas Medical Assistance Program, on or after January 1, 2018, to include any nonpregnant adult under age 65 who is a U.S. citizen or legal resident and who has been a resident of Kansas for at least 12 months, whose income does not exceed 133 percent of the federal poverty level (FPL). The bill also required referral to workforce training programs, created a health insurance coverage premium assistance program, and required submission of a waiver request to the federal government.

In his veto message, the Governor said, “I am vetoing this expansion of Obamacare because it fails to serve the truly vulnerable before the able-bodied, lacks work requirements to help able-bodied Kansans escape poverty, and burdens the state budget with unrestrainable entitlement costs.”

On April 3, the full House failed to override the Governor’s veto. The motion to pass the bill notwithstanding the Governor’s veto failed by a vote of 81–44.

  • Kentucky and Indiana

Seema Verma, the new Administrator for the Centers for Medicare & Medicaid Services (CMS), is recusing herself from the agency’s pending decision on Kentucky’s 1115 waiver, proposing a work requirement for all able-bodied Medicaid recipients.[1]   

Specifically, the waiver states, “To assist with employment, Kentucky HEALTH will require that all able-bodied working age adult members without dependents participate in the community engagement and employment initiative to maintain enrollment. Engagement activities include volunteer work, employment, caretaking, job training, or job search activities.” 

The 1115 waiver request notes that, “Children, pregnant women, individuals determined medically frail, and adults who are the primary caregiver of a dependent, including a minor child or a disabled adult dependent, are exempt from the community engagement and employment initiative.”

Ms. Verma has helped Kentucky develop a plan to overhaul its Medicaid program, and is therefore recusing herself because of a conflict of interest.

Recall that former President Barack Obama’s administration routinely denied requests by states to incorporate work requirements into their Medicaid programs. 

Kentucky’s proposal is similar to Indiana’s Medicaid expansion proposal, which was designed by Ms. Verma’s policy firm, Indianapolis-based Strategic Health Policy Solutions. Kentucky’s expansion, like Indiana, would require all enrollees to make small monthly contributions toward their coverage.

It is expected that Ms. Verma will also recuse herself from Indiana’s pending waiver. The Indiana 1115 waiver would require a referral to a work program. 

Specifically, the state “seeks to encourage participation in the Healthy Indiana Plan (HIP) Gateway to Work program in order to connect members to gainful employment, which not only improves physical and mental health, but the individual’s overall financial stability and wellbeing. To this end, the managed care entities will be required to develop member incentive programs specific to promoting employment, including but not limited to rewarding members for successful participation in the HIP Gateway to Work program through the completion of available job training, work search, or educational activities that will assist members in securing gainful employment.” 

  • Tennessee

On April 5, HB 846 was withdrawn from consideration in the Insurance and Banking Subcommittee of the Insurance and Banking Committee by the bill’s sponsor, House Minority Leader Rep. Craig Fitzhugh (D-TN). The bill would have authorized the governor to expand Medicaid pursuant to the Affordable Care Act and to negotiate with the Centers for Medicare and Medicaid Services to determine the terms of the expansion.

In a statement explaining why the bill was pulled, Rep. Fitzhugh said, “We took the bill off notice with the hopes it can be revived if and when the Subcommittee reconvenes at a date later this year.”

  • Virginia

On April 5, state lawmakers reconvened for a one-day session to consider the governors vetoes and budget amendments. The House voted 66-34 to reject the governor’s proposed budget amendment to allow him to expand Medicaid on Oct. 1 if the opportunity remains under the Affordable Care Act.

Gov. Terry McAuliffe (D-VA) released the following statement after state legislators blocked his budget amendment on Medicaid expansion: 

“By refusing to expand the [Medicaid] program, we’ve forfeited $10.4 billion and we will continue to forego $6.6 million every day we do not take action . . . Expanding Medicaid will not just make Virginians healthier by extending coverage to nearly 400,000 people, it will also strengthen our economy. We would create up to 30,000 jobs, save our budget $73 million annually, build a healthier workforce, and help struggling rural community hospitals.”

ADEA will continue to provide updates related to Medicaid expansion policy.



[1] Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to approve experimental, pilot or demonstration projects that promote the objectives of the Medicaid and Children’s Health Insurance Program (CHIP) programs. Under this authority, the Secretary may waive certain provisions of the Medicaid law to give states additional flexibility to design and improve their programs.

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