In late March, a U.S. District Judge in Washington, D.C. blocked the Trump Administration from allowing two states to impose work requirements on Medicaid recipients, a policy that experts say would deny basic health coverage to millions of Medicaid enrollees if implemented nationwide.

The rulings by U.S. District Judge James Boasberg blocked the states of Arkansas and Kentucky from imposing the requirements. In Arkansas, more than 18,000 recipients already have been stripped of coverage; thousands more were expected to be similarly affected beginning April 1, when the first wave of 2019 disenrollments were to have taken effect. In Kentucky, where the rule had not yet taken effect, state officials estimated that 100,000 people would be affected.

But the ink on Judge Boasberg’s two rulings had barely dried when the Trump Administration, through the Centers for Medicare and Medicaid Services (CMS), gave Utah permission to impose similar (albeit slightly less harsh) work requirements. The move, experts say, is a clear indication of the Administration’s intent to fight and appeal the district judge’s decisions.

Putting aside the public policy impairments of work requirements, the legal issue involved in the Arkansas and Kentucky cases is Congress’ intent when it created Medicaid. CMS Administrator Seema Verma said in the federal government’s approval letter to Utah that requiring Medicaid enrollees to work is legal because it helps make them healthier.

“Therefore we believe an objective of the Medicaid program, in addition to paying for services, is to advance the health and wellness needs of its beneficiaries, and that it is appropriate for the state to structure its demonstration project in a manner that prioritizes meeting those needs,” she wrote.

But that language seems counter to Boasberg’s rulings. In his Kentucky ruling, he wrote that using health as an objective would be “arbitrary and capricious” and an overreach of executive branch power – an overreach that also did not take into account the number of people who would be harmed.

“The Court cannot concur that the Medicaid Act leaves the Secretary so unconstrained, nor that the states are so armed to refashion the program Congress designed in any way they choose….The Secretary, most significantly, did not weigh health gains against coverage losses in justifying the approval.”

Baosberg’s two rulings applied only to Arkansas and Kentucky, not to Utah and the other six states (Arizona, Indiana, Michigan, New Hampshire, Ohio, and Wisconsin) where CMS has approved waivers for work reporting requirements.

Legal experts warn that the Trump Administration could be on shaky legal grounds.

Allison Hoffman, a law professor at the University of Pennsylvania, told Kaiser Health News that getting a federal judge to accept the premise that the primary purpose of Medicaid is improving health, as opposed to “reimbursing certain costs of medical treatment for needy persons,” as Boasberg wrote, is vital to getting work requirements through the courts. Federal officials “need a judge to buy that,” Hoffman said. “They are going to fish for a different jurisdiction to push this opinion.”

And Sara Rosenbaum, professor of health law and policy at George Washington University, told Kaiser Health News that the Trump Administration is “doubling down” by allowing a state (Utah) to add work requirements. “This is such a remarkable example of sticking a finger in the eye of the court,” she said. “We will see what happens. Because when you disrespect a court, it can backfire.”

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