The outline of a new replacement plan, presented to House members last week, shows just how far some Republican leaders hope to go in overhauling a program that has grown under the Affordable Care Act to insure one in five Americans, including more than half of the roughly 20 million people who have gained coverage under the health law.
It would give each state a fixed amount of money for each Medicaid beneficiary, instead of paying a large share of whatever it costs to cover everyone who qualifies. And it would substantially reduce the amount that the federal government pays to help cover the Medicaid expansion in Arkansas and 30 other states, a change that would most likely result in many people losing coverage.
In return, states would get far more freedom to structure their Medicaid programs as they wished. Now, even as divisions among Republicans in Congress slow efforts to repeal the Affordable Care Act, Mr. Hutchinson and other Republican governors are developing proposals to require many Medicaid recipients to have a job, participate in job training or perform community service.
“It gives dignity; it gives responsibility,” Mr. Hutchinson said in a recent interview at the State Capitol. “And if somebody wants to say, ‘That’s not for me,’ if they’re able-bodied they ought to be kicked off the system.”
Work requirements have long been central to the Republican goal of instilling a sense of “personal responsibility” in people who benefit from government programs. But it was an Arkansas Democrat, Bill Clinton, whose embrace of work requirements for welfare recipients when he was governor became the basis for the 1996 federal welfare law enacted during his presidency.
In fact, 59 percent of nondisabled adults on Medicaid do have jobs, according to the Kaiser Family Foundation. But advocates for the poor say low-income people often face numerous roadblocks in finding work. Some have criminal records. Others lack a cellphone or reliable transportation, said Mandy Davis, a social worker at Jericho Way, a resource center for the homeless in Little Rock.
“Middle-class America believes in work because we do it ourselves,” Ms. Davis said. “But we have resources, an education, transportation, a supportive family.”
Mr. Hutchinson and a few other governors, including those in Arizona, Indiana and Montana, have already sought work or job-training requirements for those who received Medicaid under the expansion over the last few years but were rebuffed by the Obama administration. President Barack Obama would allow them only to refer Medicaid recipients to job-training programs, with no requirement that they participate.
One early indication of the Trump administration’s stance will be whether it approves Kentucky’s request to require able-bodied Medicaid recipients to either work, enroll in school, get job training or volunteer 20 hours a week. Gov. Matt Bevin, a Republican, submitted the request last year.
President Trump’s nominee to run the Centers for Medicare and Medicaid Services, Seema Verma, a health policy consultant, helped with the proposal. Ms. Verma has also helped other Republican states push for, and in some cases win approval of, new rules for Medicaid enrollees, including charging them premiums and temporarily revoking coverage from those who fail to pay the premiums.
It was Mr. Hutchinson’s Democratic predecessor, Mike Beebe, who got the state’s Republican-controlled legislature to expand Medicaid by using federal funds to buy private insurance for the poor. Mr. Hutchinson said in the interview that he wanted to continue the expansion here, but that if the federal government stopped paying most of the cost as the health law requires, “we’ll just have to look at it again.”
He said he would either seek the Trump administration’s permission to impose a work requirement or seek a block grant — and, with it, leeway to create new rules — to cover those who newly qualified for Medicaid under the health law.
As a rough model, Mr. Hutchinson pointed to a work requirement for certain food stamp recipients — a federal policy that was part of the landmark 1996 welfare overhaul — that Arkansas reinstated last year. Under that rule, able-bodied adults without dependents cannot receive food stamps for longer than three months unless they are working, volunteering or getting job training for 20 hours a week.
States were allowed to suspend the requirement during the recession, but most have brought it back as unemployment has dropped. It generally applies to adults ages 18 to 49 unless they are pregnant, have dependent children or are medically certified as “unfit for employment.”
Since Arkansas reimposed the work requirement last year, its food stamp rolls have lost about 36,000 people, according to the State Department of Human Services. Mr. Hutchinson said the drop was partly explained because people had found jobs, but advocates for the poor said many appeared to have been cut off.
For now, Arkansas is sending letters to Medicaid enrollees to let them know they are eligible for “free job search assistance,” including career counseling and help writing résumés. The state is putting together a system to keep track of those who take advantage of the offer and whether they end up finding jobs. Many Medicaid recipients here already have low-paying jobs, but roughly 40 percent report having no income, according to the state.
“If you look at the statute, it is one of the purposes of Medicaid to help people attain independence and self-sufficiency,” said Dennis Smith, senior adviser for Medicaid and health care reform at the Arkansas Department of Human Services and a Medicare and Medicaid director under President George W. Bush.
But Leonardo Cuello, director of health policy for the National Health Law Program in Washington, said work requirements for Medicaid recipients would very likely be challenged in court.
“Applying work requirements to health coverage gets it exactly backward,” he said. “An individual needs to be healthy to work, and a work requirement may prevent them from getting the health care they need in order to be able to work.”
Christopher Caveney, 38, of Blytheville, recently found part-time work as a security guard after a long recovery from surgery to remove a benign tumor in his spine. Mr. Caveney has Medicaid coverage but lost his food stamps last fall because he was not working the required 20 hours a week.
“I went from being able to eat vegetables to eating Hamburger Helper every day,” said Mr. Caveney, who earns $10 an hour. “I think most people want to work, but I also know a lot of people work when it’s not necessarily in their health’s best interest.”
Mr. Cuello also said it would be difficult for states to determine which of their Medicaid enrollees were truly capable of work. Someone may be legitimately disabled but not yet approved for disability benefits, for example.
That is the case with Jimmy T. Brunson, 44, whose diabetes has caused painful neuropathy in his feet. Mr. Brunson, who was playing dominoes one recent morning at Jericho Way, a resource center for the homeless, said he sporadically found temporary jobs but had a hard time keeping them because of the pain in his feet.
Mr. Brunson said he had qualified for Medicaid under the health law and was using it to get his diabetes medication. If a work requirement was imposed, “I’d probably be out,” he said. “Even though sometimes I can get a job, you’ve got to understand — sometimes I can’t even walk.”
Daniel Foltz-Morrison, a Medicaid recipient who makes a modest income singing at churches around Little Rock, said he worried that a work requirement would reduce the Medicaid rolls without connecting many people to jobs or training.
“Are these work-force centers going to be robustly funded and have the means to identify prospective employers and make matches happen?” asked Mr. Foltz-Morrison, 29, who is also a graduate student at the University of Arkansas. “I worry that this is all for show.”
But even some of Arkansas’ poorest residents are quick to say public benefits should be conditioned on work.
“I’m glad we have it, but people should have to do something for it,” said Ms. Godinez, who had stopped by the Fishnet Missions Food Pantry in Jacksonville, outside Little Rock. “This is America, right? You’re supposed to work for what you get.”
Some who make a living helping the poor also said they were strongly against providing a public benefit to those who are physically able to work but do not.
“If you’re of able mind and body, you should be able to make something happen for yourself,” said Edward Brown, the daily operations manager at Stewpot, a soup kitchen in Little Rock. “But some people just don’t want to work — they’re too taken care of.”
Dewey Sims, the founder and chief executive of Fishnet Missions, which runs the food pantry here, agreed. “I ain’t got no damn entitlement,” he said. “I earned everything I got.”