| It’s deadline day for public input into a major policy shift in Medicaid, the federal-state health care coverage program that cares for nearly 67 million low-income and people with disabilities. The country’s first mandatory, nationwide requirement that people receiving Medicaid must document their work or other activity hours is set to take effect Jan. 1. Nebraska’s system is already in place, and some other states also are starting early. By the numbers: Even before the midnight deadline, more than 77,000 comments have poured in to the Trump administration. Fewer than a third of the comments are posted online, but some groups shared some that aren’t yet posted. How it started: The policy stems from President Donald Trump’s “One Big Beautiful Bill,” Republicans’ tax-and-spending law. Where it’s going: Certain people who are 19 to 64 years old will have to file paperwork proving they are working, in school or volunteering for at least 80 hours per month. If they don’t, and do not qualify for an exemption, they will lose their Medicaid coverage. What’s in the public responses: The agency in charge, the Centers for Medicare and Medicaid Services, adopted a stricter policy in some cases than what the law required. Many comments focused on the agency’s limits on who would be exempt from reporting their work, volunteer or school hours. Flash point over frailty: Many patients and their advocates disagreed with CMS’s interpretation of who should qualify as “medically frail” and be able to keep their coverage if they don’t send in their work hours paperwork. Patients protest: Cancer patients are among those who could lose their coverage. Among the proposed requirements that the American Cancer Society Cancer Action Network asked the Trump administration to get rid of is its requirement that people with serious or complex health problems also go through the process of documenting that they cannot work. “One of the biggest predictors of surviving a cancer diagnosis is whether someone has health insurance,” the cancer group said. A survey by the group of 1,659 cancer patients found that 72 percent said they had to miss over a month of work or other activities. The work requirements are “one of the largest changes to Medicaid eligibility policy in years,” said the National Association of Medicaid Directors, which represents all Medicaid programs, in its comments. The bipartisan group raised a number of practical concerns with the rule. One of its requests was to streamline the burden for doctors and other providers if they are asked to document that a patient is too frail to work. Democrats’ view: In a seven-page letter to CMS shared exclusively with Health Brief, the top Democrats on the Senate Finance and the House Energy and Commerce Committees said that “states are not prepared to implement the agency’s onerous, arbitrary requirements,” and that the rule “makes exceptionally cruel and arbitrary choices with regard to medical frailty, significantly subverting the congressional intent.” The proposal “forces vulnerable Americans to quite literally prove they are ‘sick enough’ to deserve health care,” said the letter by Sen. Ron Wyden (D-Oregon), and Rep. Frank Pallone Jr. (D-New Jersey). “A person in the middle of a mental health crisis or a course of cancer treatment, or someone managing severe substance use disorder, will be forced to secure explicit provider attestations linking their illness to their capacity to work. If they cannot jump through this hoop, the penalty is severe: They are cut off from the very medical care they need to survive.” The conservative viewpoint: The influential Paragon Health Institute, led by Brian Blase, sees it differently. The group pushed CMS to stand firm on the proposal’s medical frailty interpretation, and said the work requirements are administratively feasible for states to create. “Interpreting the medical frailty exemption in a manner that untethers it from [the] ability to work would be inconsistent with the statutory text and would undermine Congress’s clear intent,” the group said in an 11-page comment letter shared first with Health Brief. “The proposed rule represents an important step toward restoring accountability and integrity within the Medicaid program,” the group said, noting that states get paid more for consumers in the group that the 2010 health care law added to Medicaid than for the lower-income people the program was originally designed to cover. One reason why Congress enacted the requirements was “because the program has lost its focus on the truly vulnerable — and to incentivize upward mobility for able-bodied, working-age adults who have increasingly left the labor force,” said Paragon. Hospitals’ perspective: Hospitals have asked CMS to reconsider its interpretation of medical frailty. The American Hospital Association (AHA) also asked the Trump administration to revisit its limits on exemptions for states that want more implementation time. The agency’s approach “conditions approval on a showing of ‘extraordinary or severe barriers’ not required by statute” and “risks pressuring states to implement these complex requirements before they are operationally ready,” according to the AHA’s comments. The overall significance: The law is “expected to result in the largest rollback in Medicaid coverage and federal support in the history of the program,” said Robin Rudowitz, senior vice president at the nonpartisan organization KFF and director of the Program on Medicaid and the Uninsured. | 
