GW Law Faculty Publications & Other Works

Document Type

Article

Publication Date

2024

Status

Working

Abstract

When Kentucky and Arkansas instituted work requirements in 2018 as a condition to receiving Medicaid benefits, residents from both states sued the Trump Administration to block the program, arguing that the requirements were contrary to the Medicaid statute. In Gresham v. Azar, the DC Circuit agreed, holding that "the objective of Medicaid was to furnish medical assistance." Even though the Secretary of Health and Human Services determined that the work requirements were "likely to assist in improving health outcomes," the court concluded that "better health outcomes as [an] objective of Medicaid… lacks textual support. Indeed, the statute makes no mention of that objective."

Gresham v. Azar resulted in good policy but bad law. It is good policy because the states’ additions of work requirements were not founded on any serious science, and in fact all evidence suggests that work requirements for public assistance programs generate none of their promised benefits and instead reduce access to care for beneficiaries. It is bad law, however, first because Medicaid’s statutory language does support the promotion of better health outcomes as one of the program’s objectives, and second, because providing services that fall outside “medical assistance” is critical in improving health outcomes to beneficiaries. For this reason, non-medical services have, in fact, been a staple of healthcare delivery for decades, including some of Medicaid’s signature programs. In disallowing the work requirements the way it did, the Gresham court erected a barrier to current and future Medicaid offerings that do not provide medical assistance but nonetheless have empirically been shown to improve health.

This paper delves into the Medicaid statute to reveal its core objectives. It finds that the text of the statute charges the program with furnishing not just medical assistance but also “rehabilitation and other services” that were intended to complement and enhance the efficacy of traditional healthcare. More importantly, the statute encourages states to experiment with new healthcare delivery strategies, including those that rely on non-medical interventions, to find more affordable and cost-effective strategies to promote population health. Critically, however, the statute offers a framework—one that most states have ignored—in which states must conduct reliable policy studies and generate scientific findings to support using Medicaid funds for nonmedical interventions.

One immediate result is that the Gresham court should have disallowed Arkansas’ and Kentucky’s work requirements because they lacked empirical evidence that they promoted health outcomes, not because the programs violated the text of the Medicaid statute. A more meaningful conclusion is that Medicaid offers both an objective and a method with which states can explore nonmedical instruments to promote the health of their citizens. And precisely because public health research has identified a wealth of social, behavioral, and nonmedical interventions that have proven to be effective in promoting population health, a proper understanding of the Medicaid statute and the program’s objectives are critical in implementing effective health policy. As a second Trump Administration prepares again to institute work requirements into Medicaid, the law should prevent harmful Medicaid policies while preserving the programs true objectives.

GW Paper Series

2025-07

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