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The guidance represents a fundamental and much-disputed recalibration of the compact between the government and poor Americans for whom Medicaid coverage provides crucial access to health care.
The idea of conditioning government benefits on "work activities" was cemented into welfare more than two decades ago, when a system of unlimited cash assistance was replaced by the Temporary Assistance for Needy Families, which has work requirements and time limits.
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On the day in March when she was sworn in as administrator of the Centers for Medicare and Medicaid Services, Seema Verma dispatched a letter to governors encouraging "innovations that build on the human dignity that comes with training, employment and independence." While some conservatives pressed her agency to issue guidelines quickly, lawyers within the Health and Human Services and Justice departments jockeyed for time to construct a legal justification that could withstand court challenges.
The legal issue is that states must obtain federal permission to depart from Medicaid's usual rules, using a process known as "1115 waivers" for the section of the law under which the program exists.