Davis Joins Letter Opposing Work Requirement for Medicaid


February 14, 2018
February 14, 2018
The Honorable Alex M. Azar
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Secretary Azar:
We write in opposition to the Administration’s actions that will allow, for the first time in
the Medicaid program, a work requirement as a condition of coverage. We are deeply
concerned that linking health coverage to a work requirement not only will undermine
access to health care, but contradicts the plain text and purpose of Title XIX of the
Social Security Act and Congress’s longstanding intent for the Medicaid program. We
urge you to reconsider these actions, which are outside the boundaries of the
statutory authority provided to you under the Medicaid Act.
Congress enacted Title XIX in 1965 with a clear statutory objective to provide (1)
“medical assistance [to eligible individuals] whose income and resources are
insufficient to meet the costs of necessary medical services” and (2) “rehabilitation
and other services to help such families and individuals attain or retain capability for
independence or self-care.” To the extent Medicaid’s objectives mention
“independence,” that is explicitly in the context of helping low-income individuals,
particularly those with disabilities, maximize their integration in their communities.
Section 1115 of the Social Security Act permits states to waive certain federal
Medicaid requirements to conduct an “experimental, pilot, or demonstration project”
that achieves the goals of the Medicaid program. Notably, Medicaid's existing
flexibility has allowed states to find innovative ways to shape their programs to deliver
quality care and protect consumers against health crises while lowering costs. Today,
more than thirty states across the country have taken advantage of this flexibility by
conducting demonstrations that, in line with the statute and CMS’s (Centers for
Medicare and Medicaid Services) own stated principles, improve the coverage and
delivery of health care services. States have used Section 1115 waiver authority to
undertake innovative delivery system reform initiatives; for instance, tying provider
incentive payments to performance goals and/or better integrating primary and
behavioral health care. These types of projects indisputedly advance the health of
Medicaid beneficiaries, in line with the text and purpose of the Medicaid Act, by
improving the care beneficiaries receive and helping them to access quality health
In contrast to these demonstrations, waivers with ideologically driven policies such as
work requirements, mandatory drug testing, lock-out periods, coverage time limits,
onerous premiums, and cost-sharing not only undermine, but exceed the statutory
authority provided to the Secretary under Section 1115 and contravene longstanding
Congressional intent. Far from promoting health, these types of policies will make it
difficult for families struggling to make ends meet to access the care they need and
are entitled to under Title XIX. Ultimately, this leads to poorer health for individuals
and difficulty in maintaining successful employment, costing the system more in the
long run and negatively impacting the overall health of our communities. That is why
past Democratic and Republican Administrations have resoundingly rejected these
types of waiver requests on the basis that such provisions would not further the
program’s statutory purposes of promoting health coverage and access.
Unfortunately, this Administration has chosen to take actions furthering these types of
ideologically-based demonstrations. On January 11, CMS issued a State Medicaid
Director letter that advertised the agency’s intent to approve 1115 waivers that would
condition an otherwise eligible individual’s medical assistance on unprecedented work
requirements. On January 12, CMS announced its approval of an amendment to
Kentucky’s ongoing Section 1115 demonstration tying the receipt of medical
assistance for otherwise eligible individuals to meeting burdensome work and other
requirements. In the more than 50 years of the Medicaid program’s existence, this is
the first time CMS has approved a state request to condition access to health care on
work and related activities.
Such actions to tie health coverage to work are motivated purely on the basis of
ideology and mistaken assumptions about what Medicaid is and who it
covers. Medicaid is a part of the lives of more than 70 million elderly, low-income,
disabled adults and children that depend on the program to help provide them piece
of mind and financial security to move their families out of poverty. The reality is that
CMS’s recent actions ignore a fundamental truth: most of those who can work, are
working, but may fall through the cracks and lose their coverage due to harsh and
inflexible implementation of this ideologically-driven policy.
Medicaid demonstrations that adopt restrictive conditions on eligibility like work
requirements, mandatory drug testing, lock-out periods, coverage time limits,
disenrollment, onerous premiums, and cost-sharing threaten to impede rightful access
to care for Americans, a consequence that contravenes the statute and Congress’s
longstanding intent in creating the Medicaid program. We urge you to faithfully
administer the Medicaid Act and to reject and reconsider Section 1115 demonstration
requests that jeopardize the health and financial security of Medicaid beneficiaries.
Democratic Leader Nancy Pelosi
Democratic Whip Steny H. Hoyer
Assistant Democratic Leader James E. Clyburn
Democratic Caucus Chairman Joseph Crowley
Democratic Caucus Vice Chairman Linda Sánchez
Energy and Commerce Ranking Member Frank Pallone, Jr.
Energy and Commerce Subcommittee on Health Ranking Member Gene Green
Alma S. Adams (NC-12)
Pete Aguilar (CA-31)
Nanette Diaz Barragán (CA-44)
Karen Bass (CA-37)
Joyce Beatty (OH-03)
Ami Bera (CA-07)
Donald S. Beyer Jr. (VA-08)
Sanford D. Bishop Jr. (GA-02)
Earl Blumenauer (OR-03)
Lisa Blunt Rochester (DE-AL)
Suzanne Bonamici (OR-01)
Madeleine Z. Bordallo (GU-DL)
Brendan F. Boyle (PA-13)
Robert A. Brady (PA-01)
Anthony G. Brown (MD-04)
Julia Brownley (CA-26)
Cheri Bustos (IL-17)
G.K.Butterfield (NC-01)
Michael E. Capuano (MA-07)
Salud O. Carbajal (CA-24)
Tony Cárdenas (CA-29)
André Carson (IN-07)
Matt Cartwright (PA-17)
Kathy Castor (FL-14)
Joaquin Castro (TX-20)
Judy Chu (CA-27)
David N. Cicilline (RI-01)
Katherine M. Clark (MA-05)
Yvette D. Clarke (NY-09)
Wm. Lacy Clay (MO-01)
Emanuel Cleaver (MO-05)
Steve Cohen (TN-09)
Gerald E. Connolly (VA-11)
John Conyers Jr. (MI-13)
Joe Courtney (CT-02)
Elijah E. Cummings (MD-07)
Danny K. Davis (IL-07)
Susan A. Davis (CA-53)
Diana DeGette (CO-01)
John K. Delaney (MD-06)
Rosa L. DeLauro (CT-03)
Suzan K. DelBene (WA-01)
Val Butler Demings (FL-10)
Mark DeSaulnier (CA-11)
Theodore E. Deutch (FL-22)
Debbie Dingell (MI-12)
Michael F. Doyle (PA-14)
Keith Ellison (MN-05)
Eliot L. Engel (NY-16)
Anna G. Eshoo (CA-18)
Adriano Espaillat (NY-13)
Elizabeth H. Esty (CT-05)
Bill Foster (IL-11)
Lois Frankel (FL-21)
Marcia L. Fudge (OH-11)
Tulsi Gabbard (HI-02)
Ruben Gallego (AZ-07)
Vicente Gonzalez (TX-15)
Al Green (TX-09)
Raúl M. Grijalva (AZ-03)
Luis V. Gutiérrez (IL-04)
Colleen Hanabusa (HI-01)
Alcee L. Hastings (FL-20)
Denny Heck (WA-10)
Brian Higgins (NY-26)
Jared Huffman (CA-02)
Sheila Jackson Lee (TX-18)
Pramila Jayapal (WA-07)
Hakeem S. Jeffries (NY-08)
Eddie Bernice Johnson (TX-30)
Henry C. "Hank" Johnson Jr. (GA-04)
Marcy Kaptur (OH-09)
William R. Keating (MA-09)
Robin L. Kelly (IL-02)
Joseph P. Kennedy III (MA-04)
Ro Khanna (CA-17)
Ruben Kihuen (NV-04)
Daniel T. Kildee (MI-05)
Derek Kilmer (WA-06)
Raja Krishnamoorthi (IL-08)
James R. Langevin (RI-02)
Rick Larsen (WA-02)
John B. Larson (CT-01)
Brenda L. Lawrence (MI-14)
Al Lawson Jr. (FL-05)
Barbara Lee (CA-13)
Sander M. Levin (MI-09)
John Lewis (GA-05)
Ted Lieu (CA-33)
David Loebsack (IA-02)
Zoe Lofgren (CA-19)
Alan S. Lowenthal (CA-47)
Nita M. Lowey (NY-17)
Ben Ray Luján (NM-03)
Michelle Lujan Grisham (NM-01)
Carolyn B. Maloney (NY-12)
Sean Patrick Maloney (NY-18)
Doris O. Matsui (CA-06)
Betty McCollum (MN-04)
A. Donald McEachin (VA-04)
James P. McGovern (MA-02)
Jerry McNerney (CA-09)
Gregory W. Meeks (NY-05)
Grace Meng (NY-06)
Gwen Moore (WI-04)
Seth Moulton (MA-06)
Jerrold Nadler (NY-10)
Grace F. Napolitano (CA-32)
Richard E. Neal (MA-1)
Richard M. Nolan (MN-08)
Donald Norcross (NJ-01)