The Independent View: Trump Exempts Most AZ Tribes from Medicaid Work Rules

Most Native Americans Enrolled in Medicaid in Arizona Won't be Forced to Work to Keep their Health Insurance under New Rules the Trump Administration Approved for the State, a move that likely defuses a Yearlong Controversy over Tribal Sovereignty that had Split Department of Health & Human Services (HHS) Leadership and Alarmed some Members of Congress.

The Administration's Top Medicaid Official described the Decision to Exempt Members of Federally recognized Tribes as a Compromise over an Issue that nearly Derailed Arizona's Request to add Medicaid Work Requirements, a Top Priority for President Trump's Health Department. However, some Native American Populations who are Not Enrolled Citizens of their Tribes are still Subject to New Employment Rules and could Lose their Coverage for Not Working.

The Administration's Approval Friday could also pave the way for other States to Require some American Indian Enrollees of the Low-Income Health Insurance Program to Work.

Arizona, like some other States seeking New Work Rules, asked Federal Medicaid Officials to Exempt All American Indian Populations from the Requirement, Citing Tribal Sovereignty. However, Administration Lawyers last year determined the Tribes were a Racial Group and Not Separate Governments, and that Granting them an Exemption from the Work Requirement would have amounted to an Illegal Racial Preference.

The Position raised Concerns among some GOP Lawmakers in Rural States and Alarmed the Tribes, which argued it Reversed Centuries of Protections Enshrined in the Constitution and Upheld by the Supreme Court. “There were a lot of complex legal issues here,” CMS Administrator Seema Verma said in an Interview. “I think that we were able to find a middle ground.”
Arizona and the Centers for Medicare and Medicaid Services could Not say how many Individuals Not Enrolled with Tribes would have to comply with the Work Rules.

Under the Arizona Waiver, Medicaid Enrollees between the ages of 19 and 49 who are Not Exempt will have to Work at least 80 hours per month, or Participate in Other Activities like Job Training or Community Service, to Maintain their Health Coverage. The Administration and State Officials had been Negotiating for Months over the Plan.

Verma suggested her Agency’s Approach was the most Feasible Path given the competing Arguments from Administration Lawyers and Tribal Groups. “We believe this narrower exemption is consistent with the unique status of tribal governments,” the Agency wrote in a Letter to Arizona on Friday. Tribal Leaders said the Administration's Decision largely Satisfies their Concerns, but they said the Exemption doesn’t go Far Enough to Ensure that All American Indian Populations would Not be Subject to the New Rules.

For example, in other States, including Alabama, Georgia, and North Carolina, Not All Tribal Populations are Recognized by the Federal Government. In Arizona alone, there are American Indian Populations who are Not Enrolled in their Tribes but are still Eligible for Care through Indian Health Service Facilities, said Ron Allen, Chairman of the CMS Tribal Technical Advisory Group.

Verma on Friday indicated that the Arizona Decision would Apply more broadly to other States seeking Work Rules and Requesting Exemptions for Tribal Populations. “Once we do something for one state, we’re trying to be consistent,” she said.

With the Approval in Arizona, the Trump Administration has Granted Employment Conditions for Medicaid Benefits in Eight States, even as Lawsuits from Enrollees are trying to Overturn the Requirements in Arkansas and Kentucky. In Arkansas, the First State where the Work Rules took effect, more than 18,000 Medicaid Enrollees in Four Months have been Removed from the Program for Failing to Report enough Hours.

The Arizona Requirement is set to take effect in January 2020.