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    Kentucky rushes to remake Medicaid as other states prepare to follow

    LOUISVILLE, Ky. — With approval from the Trump administration, Kentucky is rushing to roll out its first-in-the-nation plan to require many Medicaid recipients to work, volunteer, or train for a job — even as critics mount a legal challenge to stop it on the grounds that it violates the basic tenets of the program.

    At least eight other Republican-led states are hoping to follow — a ninth, Indiana, has already won permission to do so — and some want to go even further by imposing time limits on coverage.

    Such restrictions are central to GOP efforts to change Medicaid, the safety net program that has provided free health insurance to tens of millions of low-income Americans for more than 50 years.

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    The ballooning deficits created by the budget deal that President Trump signed Friday and the recent tax bill are likely to add urgency to the party’s attempts to wring savings from entitlement programs.

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    House Speaker Paul Ryan, a Wisconsin Republican, said Thursday that addressing entitlement spending is “what you need to do to fully deal with this debt crisis,” though Senator Mitch McConnell, a Kentucky Republican and majority leader, has ruled out doing so this year.

    As Kentucky pushes forward, many who work with low-income people are worried that the thicket of new documentation requirements in Medicaid will be daunting; many have little education and struggle with transportation, paying for cellphone minutes, and getting access to the internet.

    Not only that, they note, the new rules will add the type of administrative costs and governmental burdens that Republicans tend to revile.

    On a recent Monday, Bill Wagner, who runs primary care clinics in poor neighborhoods, listened tensely as a state health official explained how the state would enforce the complex and contentious new rules.

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    The 20 hours a week of work, job training, or volunteering? Ten regional workforce boards will monitor who complies, said the official, Kristi Putnam.

    The monthly premiums of $1 to $15 that many will now owe? The managed care companies that contract with the state will collect them.

    The “rewards dollars” that many will need to earn to get their teeth cleaned or their vision checked? They’ll be tracked through a new online platform, where Medicaid recipients will also be expected to upload their work, volunteer, or training hours.

    After four years of signing up thousands of people for coverage under the health law’s expansion of the Medicaid program, Wagner told the room, “We’re shifting our focus from helping people gain coverage to helping people keep it.”

    The rationale of Governor Matt Bevin and other supporters is that Medicaid was created for the most vulnerable citizens — those who aren’t only poor, but pregnant, elderly, children, or disabled — and that for everyone else, working or otherwise engaging in their community will provide dignity and better health.

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    About 500,000 more Kentuckians have gotten Medicaid under the Obamacare expansion, and the state estimates some 350,000 of them will be subject to the new work rules.