Highlight on Maine: Able-bodied MaineCare recipients could be subject to more stringent requirements

“Able-bodied adults” would be subject to work/education requirements and a lifetime limit of five years under changes Mary Mayhew, director of the Maine Department of Health and Human Services, proposed to Maine’s Medicaid program, MaineCare. In a letter to HHS Secretary Tom Price, Mayhew said she would be seeking the changes in a forthcoming formal 1115 demonstration waiver request.

Mayhew’s letter comes at the heels of a referendum campaign to expand Medicaid in Maine at, according to Mayhew, a cost of $400 million over the next five years. A second motivation is the apparently sympathetic Trump Administration, which has proposed replacing Medicaid with block grants.

Mayhew said that the state has expanded its Medicaid program over decades, resulting in the use of hundreds of millions of state dollars “to turn Medicaid into an entitlement program for working-age, able-bodied adults.” MaineCare serves 270,000 individuals, just over 20 percent of Maine’s population, which, Mayhew said, represents a 22 percent reduction in enrollment since 2011.

Mayhew’s Medicaid proposals include the following:

  • work or education requirements for able-bodied adults in the Medicaid program, similar to the work requirements for Temporary Assistance for Needy Families (TANF) or Able-Bodied Adults Without Dependents (ABAWDs) in the Supplemental Nutrition Assistance Program (SNAP);
  • a five-year lifetime limitation on able-bodied adults’ eligibility for Medicaid;
  • limiting non-emergency transportation (NET) to situations where the underlying service to or from which individuals are being transported is a required Medicaid service and requiring them to access existing transportation resources before accessing NET;
  • requiring monthly premiums for adults who are able to earn income;
  • requiring monthly coinsurance of a set amount (approximately $20) for all members, cost-sharing of $20 for using the emergency department, and fees for missed appointments;
  • applying a reasonable asset test to Medicaid; and
  • waiver of the retroactive coverage of services incurred during the 90 days before Medicaid eligibility.


Medicaid work requirements may be counterproductive, undo reform efforts

An analysis of proposed changes to state Medicaid programs, which include restructuring funding and implementing a work requirement, suggests that eligibility and access to health care would be diminished. The Center on Budget and Policy Priorities (CBPP) believes that such a requirement would not result in much long-term employment gain and argued that families in programs imposing a work requirement are more likely to end up in deep poverty, with neither assistance nor wages.

Work requirements

The CBPP researched programs with work requirements and found that although employment increased modestly in the short-term, work requirement programs had the same or lower employment compared to programs without such requirements at the five-year mark. The portion of those with incomes below half of the poverty line, known as deep poverty, ended up rising in seven of 11 programs studied that had work requirements. This resulted in many participants ending up with no cash assistance and no employment.

Those who can work, do

The CBPP found that three-fourths of non-elderly and child Medicaid enrollees live in a family where at least one person works. In California, for example, Medicaid covers 10 percent of the population that works full time, and 20 percent of those employed part time. The report also indicated that states providing supportive employment services to those with disabilities have been successful in helping enrollees find and keep jobs.

CBPP’s analysis finds that many Medicaid enrollees do not work because they have health or family-related barriers to maintaining employment. These barriers include a role as a primary caregiver, behavioral health issues, limited education, and a criminal history. In 2012, the unemployment rate for those experiencing mental illness hovered at 17.8 percent, but the National Alliance for Mental Illness (NAMI) estimated that many could be successfully employed if they received supportive services. CBPP believes that it would be difficult work programs to identify those who could not work in order to exempt them from work requirements.


The CBPP found that the work requirement would target unemployed parents or those with the aforementioned barriers to working. Losing coverage due to the inability to work would result in loss of access to primary and preventive care gained under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). Hospitals would lose payment for treating the newly covered in states that have expanded Medicaid, and enrollees who are obtaining care that may ultimately better their chances of obtaining and sustaining employment could lose access to that care.