Last week, CMS Administrator Seema Verma gave a major policy address to the National Association of Medicaid Directors. She made two things crystal clear. First, she cares about protecting “deserving” Americans: “…our safety net should be stronger to ensure that no deserving Americans fall through the cracks.” Second, she does not believe that the Medicaid program should cover “able-bodied” Americans unless they work: 

“While many responded to [the Medicaid] expansion with celebration, we shouldn’t just celebrate an increase in the rolls, or more Medicaid cards handed out. For this population, for able-bodied adults, we should celebrate helping people move up, move on, and move out. We have a moral responsibility to do more than just give them a card, we have a responsibility to give them care. The thought that a program designed for our most vulnerable citizens should be used as a vehicle to serve working age, able-bodied adults does not make sense….”

Administrator Verma framed this as “a new day for Medicaid at CMS … turning the page and starting a new chapter.” In fact, she is turning the page back not just to Medicaid’s first chapter, over 50 years ago, when eligibility for children and families was linked to receipt of cash assistance through Aid to Families with Dependent Children (AFDC). She is turning it back to 16th century England.

Starting in 1552, the English Parliament enacted a series of laws to address poverty, culminating in The Elizabethan Poor Law (formally the 1601 Act for the Relief of the Poor, 43 Eliz I Cap. 2). These laws effectively divided the poor into two buckets: the “deserving” and the “undeserving.” Some of the “deserving” received assistance; the “undeserving” did not.

There were two broad classes of “deserving” poor: the “able-bodied” who were able and willing to work but didn’t have work; and the “impotent poor” who were too old or ill or young to be able to work. The two classes were treated very differently. The only relief available to the “able-bodied” was to be “set to work” in a House of Industry. This was on account of their perceived moral failing. The “impotent poor,” in contrast, were to be cared for in an almshouse or poorhouse. Pauper children were to become apprentices to learn a trade to support themselves when they grew up.

The “undeserving” poor included the idle and vagrants; they received no relief and could be sent to the House of Correction.

This moral framework animates the administrator’s remarks: “We have a higher purpose than just handing out Medicaid cards and being a financier of healthcare.” It will evidently inform her decisions on Medicaid state plan amendments, waivers, and regulations as well: “We will not just accept the hollow victory of numbers covered, but will dig deeper and demand more of ourselves and of you.”

Here’s the rub. This is 21st century America, not 16th century England. Medicaid is a health insurance program, not a welfare program. Low-income children and parents no longer have to receive cash assistance in order to qualify for Medicaid. The Medicaid statute does not distinguish between “deserving” and “undeserving” low-income Americans, and it does not identify a class of “able-bodied” Americans, much less require that they work as a condition of receiving needed health care coverage.

Congress may want to return the Medicaid program back to 1965 or even to 1552. Of course, that would completely unwind the progress our country has achieved in reducing the uninsured rate among children to less than 5% and the uninsured rate among adults to 7% in Medicaid expansion states (and 15% in non-expansion states). But under the U.S. Constitution, that policy – and moral — decision is the prerogative of the Congress, not Administrator Verma.