Under the 2018 Trump Administration, the Centers for Medicare and Medicaid Services (CMS) issued guidance for state Medicaid waiver proposals that would make work or other community engagement a requirement for continued Medicaid eligibility or coverage (Centers for Disease Control and Prevention, 2018). This policy was authorized under Section 1115 Medicaid waivers, which permits states to use Federal Medicaid or CHIP funds to test new approaches in Medicaid that differ from what is required by federal statute. The proposals vary from state to state, but essentially, low-income adults — except for pregnant women, people ages 65 and older, and those receiving disability benefits— would need to meet and report a certain number of work hours each month to qualify or keep their Medicaid coverage.

CMS claimed that the new rules would promote better health through incentivizing employment in states that choose to opt-in. However, data from several states that have implemented this new policy show thousands losing or in danger of losing healthcare coverage. In Arkansas’ ten-month implementation of the work requirement policy, more than 18,000 people lost coverage in the first 7 months. Since then, several states are reconsidering implementing or continuing to implement work requirements. Almost 17,000 people in New Hampshire and 80,000 people in Michigan were at risk for losing their coverage had state policymakers and court judges not put the policy on hold (Wagner & Schubel, 2020). Although CMS approved twelve states for the work requirement waivers, no states have been implementing it since the coronavirus pandemic due to court decisions, voluntary moratoriums states have adopted, and federal protections put in place during the pandemic (Wagner & Schubel, 2020).

To counteract the harmful effects of the 1115 work requirement waivers under the Trump Administration, the new Health and Human (HHS) Services secretary under the Biden Administration may act to rescind the 2018 policy issued by CMS and reject all pending waiver applications (Huberfeld & Schafer, 2021). The HHS secretary may also seek to withdraw or renegotiate the approved work requirement waivers. However, since states can choose to appeal such decisions, the fate of the remaining states’ 1115 waivers may ultimately rest with federal courts. On January 28th, Biden issued an executive order that would require agencies to review any policies, including work requirement waivers, that could reduce coverage or otherwise undermine Medicaid. Until this investigation is complete, at-risk populations will continue to face injustices as they are denied the fundamental right to health care, including occupational therapy services, in the aftermath of a global pandemic.

Occupational therapists have already been advocating for states to include occupational therapy in their Medicaid programs as the federal government currently allows all states to decide that for themselves. But if a person isn’t eligible for Medicaid or can’t afford private insurance, then occupational therapy for those who need it will no longer be an option. Occupational therapists must join other advocates in contacting their local representatives to let them know they are not in favor of their state opting into the 1115 work requirement waiver, as it is no longer in the interest of the public.

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