The Trump administration’s decision last week to allow states to require Medicaid recipients to work, volunteer, or attend classes could impact the health of millions of Americans, according to experts.

There’s nothing wrong with encouraging people to work, the experts say, but the purpose of the Medicaid program is solely to provide access to healthcare, not address other economic issues.

“Medicaid is not a work program. It’s designed to be a health program. This is really just counterintuitive to what the program is supposed to be,” said Leni Preston, vice president of Consumer Health First, which promotes health equity in Maryland.

Preston said that 39 percent of the Medicaid recipients in Maryland who aren’t working are disabled. Nationwide, that figure is 36 percent, .

Finding work or other forms of what the Trump administration is calling “social engagement” may not be feasible for many of them. Securing documentation to prove it may not be feasible for others.

The impacts, Preston said, will be felt throughout the pool of recipients.

“Any talk of a work requirement would scare a lot of people off and discourage them from applying at all. That’s just human nature,” she told Healthline. “The end result is that people are going to lose their coverage, coverage they deserve and were promised… It really does impact the Medicaid population as a whole.”

The Department of Health and Human Services, which oversees Medicaid at the federal level, thinks those concerns are overblown.

The decision creates flexibility, agency officials say, allowing states to experiment a bit more to see if new rules can help reduce costs and make recipients more independent.

The Centers for Medicare & Medicaid Services “believes that Medicaid has a broader purpose than just giving individuals a health insurance card,” an agency spokeswoman told Healthline.

“As individuals obtain employment and increase earnings, states may see a reduction in the number of nondisabled adults enrolled in their programs as they rise out of poverty and off public assistance,” she said.

The spokeswoman called the program a “demonstration project” and said that states will be required to monitor health outcomes, including individuals who lose coverage due to new work requirements or, she added, through gaining new employer-sponsored insurance.

Changing the rules

Medicaid insures one in five Americans through state and federal funding.

An eligibility as part of Obamacare allowed states to expand coverage to adults with incomes up to $16,642 a year.

That allowed more of the “working poor” to obtain health coverage through the program.

That spurred some states, not willing to insure what they saw as able-bodied adults, to reject the expansion. Some of those states then sought federal permission to require potential new recipients to be working before granting them health coverage. The Obama administration had rejected those requests.

Since the Trump administration earlier this month, 19 states have expressed interest in imposing a work requirement, including Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah, and Wisconsin.

With a work requirement, it’s possible Medicaid could be expanded in those states.

It’s also possible current Medicaid recipients could lose coverage in some of those states.

Arizona, Arkansas, Indiana, Kentucky, and New Hampshire are eyeing work requirements despite having already expanded Medicaid coverage through Obamacare.

officials announced they had been granted permission to impose work requirements the day after the Trump administration announcement. It will require some Medicaid enrollees to work, volunteer, or participate in job training or job searches for at least 80 hours a month.

But it’s also possible states will include enough exemptions from the work requirements that the loss of coverage may be minimal.

The new federal rules allow states to include caregiving for the elderly or a disabled child as tasks that meet the work requirement. Children, disabled, elderly, or pregnant women would be exempt.

Exemptions would also be required for those deemed “medically frail” and states would need to “make reasonable modifications for individuals with opioid addiction and other substance use disorders,” according to the CMS spokeswoman.

Providing proof

But obtaining documentation to track all that could be a problem for many recipients, said Preston.

The largest sector in which Medicaid recipients are employed is restaurant and food service. That industry employs 1 in 10 Medicaid recipients who have jobs, according to the Kaiser Family Foundation.

Many working in the sector may be being paid off the books without knowing it, Preston said. Others — both those already working and those eligible for exemptions — may not have the time, ability, or other means to obtain verifications or waivers.

“If you’re disabled and having a hard time navigating the system to prove you’re eligible, the potential is you’re going to lose your coverage,” she said.

How many people could potentially lose coverage is difficult to say. Most people who receive Medicaid already work, particularly those in the “able-bodied,” non-elderly group potentially subject to new work requirements. Nearly 8 in 10 non-disabled, non-elderly adults are in families with at least 1 part-time or full-time worker, .

And 60 percent of recipients are themselves working, 42 percent of them full time.

Of the ones that aren’t, 36 percent said they weren’t working because they were ill or disabled, and 30 percent because they were taking care of home and family.

Does Medicaid encourage work?

Some officials have raised the prospect that working, even if forced to do so, promotes health. Preston counters that the quality of the work is what really matters.

“Restaurant jobs are low paying with low job security, so they do not promote health in any way whatsoever,” she said.

But the inverse does appear to be true — Medicaid coverage has been tied to an increased likelihood of working.

“Research shows that Medicaid expansion has not negatively affected labor market participation, and some research indicates that Medicaid coverage supports work,” according to the Kaiser Family Foundation. “Individuals have reported that receiving medication for conditions like asthma or rheumatoid arthritis through Medicaid is critical in supporting their ability to work.”

Opponents of the Trump administration decision contend there’s nothing wrong with being encouraged to work, but that the encouragement shouldn’t be via the threat of losing health coverage.

Regarding the volunteer provision in the new rule, Preston asked, “Are we really going to be asking these people to work for nothing in the midst of trying to cope with everything else? It just doesn’t make sense.”

She thinks government would be better off providing more pathways — outside of the Medicaid program — that help people find work.

The Department of Health and Human Services “says to treat this like an experiment,” she said. “The end result is they’re experimenting with the health and well-being of Americans.”