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Teresa Loman of Erlanger, Kentucky, who works two part-time jobs and is worried about Medicaid work requirements, draws with her daughter, Leona Hunter. Photo: Carolyn Van Houten / The Washington Post via Getty Images

The Medicaid “community engagement” waiver awarded to Kentucky, and similar waivers expected to be awarded to at least eight other states, are viewed by both advocates and critics as a form of "welfare reform" for Medicaid. They require that beneficiaries work or take steps towards work in return for Medicaid coverage.

Reality check: But they do only half of what the 1996 welfare overhaul did. They provide no new federal funding for job training, job search, transportation, child care or the other support services that were the government’s part of a new two-way bargain with beneficiaries. And without that two way street, what they will mainly accomplish is to reduce the Medicaid rolls by erecting barriers to coverage.

The back story: Back in the Reagan era, a rewrite of the welfare system was first sold on the idea of a “reciprocal obligation” between beneficiaries and government. Beneficiaries had the obligation to take steps that would lead to employment, and states had the obligation to provide services — most importantly job training and child care — that enabled them to do so.

As New Jersey's Human Services Commissioner, I launched a large early generation welfare reform program called Realizing Economic Achievement (REACH) for Republican Gov. Tom Kean. This meant an infusion of new funds for these services, especially child care.

Liberals were attracted by the new obligations for government and the new funding, and conservatives liked the work requirement. It was controversial, but an implicit deal was made in New Jersey and other states and nationally.

The 1996 welfare overhaul signed into law by Bill Clinton was built on the same tradeoff.  Now, states spend just a quarter of their federal Temporary Assistance for Needy Families dollars on cash assistance. The rest go to child care, job training and other job-related services and supports.

Why this is different: The Medicaid work requirements, on the other hand, place the burden mostly on beneficiaries, and are coupled with other hoops beneficiaries have to jump through in the Kentucky waiver: They can lose coverage if they fail to pay new income-related premiums imposed under the waiver. They can also be cut off if they don't report income or renew eligibility on a specified schedule.

Context: The work requirement is a fundamental shift in policy and has sucked up most of the oxygen, but it will likely affect only a small number of beneficiaries who are not already working or exempted from the requirements. A lot depends on how states implement them, but these other provisions could have a larger impact in terms of reducing coverage.

The impact: States submitting waivers are projecting coverage losses, with Kentucky projecting 95,000 fewer residents on Medicaid each month.

What to watch: Mississippi has submitted a waiver request asking for federal Medicaid matching funds for the employment and training component of its Medicaid work requirement. With such funding seemingly proscribed in the Centers for Medicare and Medicaid Services guidance to states, how will the agency respond?

  • Also worth watching: will the Medicaid work requirement reportedly being developed by a Democratic governor in Louisiana look different from those developed in red states?

The bottom line: Whatever your view of welfare reform, to paraphrase Senator Lloyd Bentsen’s famous quip about President Kennedy to Dan Quayle: I knew welfare reform, and this isn’t it.

Go deeper

America's child care sticker shock

Illustration: Sarah Grillo/Axios

Parents looking to return to the job market may find child care options have gotten pricier — and that's if they can enroll their kids at all.

Why it matters: The fate of the recovery partially relies on the return of parents who left the workforce to care for their children.

Biden's major border shake-up

A migrant family waits to be taken to a Border Patrol processing facility after crossing the Rio Grande River. Photo: Brandon Bell/Getty Images

Vice President Kamala Harris' trip to the border on Friday will play out amid the Biden administration widening shake-up of U.S. border policy and leadership.

Driving the news: Rep. Henry Cuellar (D-Tex.) tells Axios that he's been advised by a border official that as soon as mid-July the Biden administration will end all use of Title 42, a Trump-era policy citing coronavirus as rationale to block migrants at the border.

DeSantis signs law requiring college faculty, students to take surveys on beliefs

Florida Gov. Ron DeSantis. Photo: Joe Raedle/Getty Images

Florida Gov. Ron DeSantis (R) signed legislation requiring state colleges and universities to annually survey their students, faculty and staff about their beliefs to ensure "viewpoint diversity and intellectual freedom."

Why it matters: The legislation doesn't specify for what the survey results will be used, but at a press conference on Tuesday DeSantis said that schools found to be "indoctrinating" students aren't "worth tax dollars" and are "not something we’re going to be supporting going forward."

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