By Tony Pugh

WASHINGTON — After allowing states to impose work requirements for Medicaid enrollees, the Trump administration is now pondering lifetime limits on adults’ access to coverage.

Capping health care benefits — like federal welfare benefits — would be a first for Medicaid, the joint state-and-federal health plan for low-income and disabled Americans.

If approved, the dramatic policy change would recast government-subsidized health coverage as temporary assistance by placing a limit on the number of months adults have access to Medicaid benefits.

The move would continue the Trump administration’s push to inject conservative policies into the Medicaid program through the use of federal waivers, which allow states more flexibility to create policies designed to promote personal and financial responsibility among enrollees.

However, advocates say capping Medicaid benefits would amount to a massive breach of the nation’s social safety net designed to protect children, the elderly and the impoverished.

In January, the Trump administration approved waiver requests from Kentucky and Indiana to terminate Medicaid coverage for able-bodied enrollees who do not meet new program work requirements. Ten other states have asked to do the same.

“We must allow states, who know the unique needs of their citizens, to design programs that don’t merely provide a Medicaid card but provide care that allows people to rise out of poverty and no longer need public assistance,” said a statement posted on Twitter on Monday by Medicaid administrator Seema Verma.

At least five states — Arizona, Kansas, Utah, Maine and Wisconsin — are seeking waivers from the Trump administration to impose lifetime Medicaid coverage limits.

The proposals reflect the administration’s belief that Medicaid coverage should be retained for vulnerable populations like children, pregnant women and those with disabilities. Proponents of the change say the program’s coverage for healthy adults, particularly those with no dependent children who received expanded coverage under Obamacare’s Medicaid expansion, should be curbed.

Critics, however, say Medicaid time limits will pose an enormous administrative burden by requiring states to track recipients’ employment, eligibility and disability status. It could also shave valuable coverage months from people with health problems that impede their ability to work.

In addition, low-wage workers who may not get health coverage through their jobs could also reach their Medicaid coverage limit “as if it’s their fault that their job isn’t offering insurance,” said Leonardo Cuello, director of health policy at the National Health Law Center. “And this would happen to thousands upon thousands of people across the country,” if the policy catches on nationwide.

Others argue that attaching time limits and work requirements to Medicaid coverage does not meet a basic requirement of HHS waiver experiments and demonstration projects: to further the objectives of the Medicaid program, such as improving coverage, health outcomes and access to providers.

“All of these policies that we are seeing are inconsistent with the objectives of Medicaid. They don’t seem to have a legal basis and, as such, our stance is that they should not be approved. And we will work very hard with our partners to make that opinion well known,” said Suzanne Wikle, a senior policy analyst at the Center for Law and Social Policy.

But unlike capping cash welfare assistance or food stamp benefits, time-limiting health coverage runs the risk of pushing sick people into costly emergency rooms where they’ll receive indigent care paid for by taxpayers.

“I think you have to be very thoughtful here in a way that’s quite different from cash assistance,” said Gail Wilensky, a senior fellow at Project HOPE who ran the Medicaid program from 1990 to 1992 under President George H.W. Bush. “It depends on what the safeguards and defaults are in a program like this. Otherwise it does not make a lot of sense and seems to be cruel and inappropriate.”

Arizona and Utah both want a 5-year lifetime limit on coverage. Utah’s would apply only to childless adults and would come “with the expectation that they do everything they can to help themselves before they lose coverage,” according to the state’s waiver application.

In Arizona, time-limited coverage would only accrue during months when enrollees don’t meet their work requirements, which the state is also seeking in their waiver application. Wisconsin wants to limit lifetime coverage for childless adults to 48 months. Kansas would limit coverage to 36 months.

In Utah, Wisconsin and Kansas, the time-limited coverage would apply even to Medicaid enrollees who meet employment and work requirements.

In Maine, Medicaid enrollees who don’t meet program work requirements could only get up to three months of coverage in a 36-month period. And only in special circumstances could these enrollees get an extra month of coverage.

The Obama administration previously denied Arizona’s request for Medicaid coverage limits and work requirements, saying they didn’t meet the program’s goal of ensuring coverage for vulnerable populations.

Jessica Schubel, a senior policy analyst at the Center on Budget and Policy Priorities, said there’s a “50-50 chance” that the Trump administration approves the time limits.

“I feel like the Trump administration is hell-bent on trying to keep people out of coverage … So, I don’t know. I hope not, but I’m not holding my breath. And I guess I wouldn’t be too terribly surprised to see it approved,” said Schubel, a former senior policy advisor at HHS’ Center for Medicare and Medicaid Services during the Obama administration.

The Department of Health and Human Services did not respond to a request for comment for this story.