[Annotated] How the Trump administration is reshaping Medicaid

Republican-led states are using waivers to^[각주:1] impose work requirements for the first time ever

American lawmakers are acutely afraid of^[각주:2] rewarding the loafing poor^[각주:3]. For that reason, Congress has set strict work requirements on^[각주:4] federal food assistance^[각주:5] and cash welfare. The Trump administration is now steadily doing the same for Medicaid, as America's health-insurance programme for the poor is known. On January 11th the Centres of Medicare and Medicaid Services (CMS) issued a memo inviting states to^[각주:6] apply for waivers that would include "work and community engagement requirements" on the theory that this would both improve health and help families "rise out of poverty and attain independence^[각주:7]". Ten states, all Republican-led, quickly took up the offer^[각주:8]. Michigan, another Republican-controlled state, has contemplated a waiver of its own which would impose some of the strictest work requirements yet seen. The impetus is^[각주:9] less financial than moral^[각주:10] - an attempt to sort the deserving^[각주:11] poor from^[각주:12] the chaff^[각주:13]. 

The state proposals to reform Medicaid are fairly similar. Exempting the pregnant^[각주:14], disabled and others, all adults would have to work, volunteer or undergo job training to^[각주:15] continue receiving benefits^[각주:16]. Kentucky, the first to send a plan to CMS, set the minimum at 20 hours per week. Michigan had proposed 29 hours per week. After one warning, those who failed to meet the requirement would be locked out of coverage for a year^[각주:17]. 

The most controversial portion of^[각주:18] Michigan's plan would exempt counties with high unemployment rates, defined as 8.5% or higher, from the work requirements. Only 17 rural counties, with a total population that is 91% white, would have reached the threshold^[각주:19]. The residents of struggling cities like Flint and Detroit, which have high unemployment rates and are disproportionately black^[각주:20], would not have qualified^[각주:21] because surrounding counties are better-off^[각주:22]`. "Lot of folks that really need health care would lose it," says Jim Ananich, a state senator from Flint. 

The exempt counties are^[각주:23] reliably Republican outposts^[각주:24], so currying favour with^[각주:25] constituents^[각주:26] is a likelier explanation than outright^[각주:27] racial animus^[각주:28]. "It was an honest effort to recognize that across the state there are variations in the ability to get jobs. There was no thought given to the R-word on this," says Mike Shirkey, the Michigan state senator sponsoring^[각주:29] the Medicaid legislation^[각주:30]. Yet the effort has an unpleasant, and familiar, smell. Martin Gilens, a political scientist at Princeton University, has shown that antipathy towards^[각주:31] welfare in the 1990s was driven by hostile attitudes toward blacks, who were thought of as lazy and undeserving^[각주:32]. 

A costly point^[각주:33]

Though the unemployment provision was^[각주:34] in the bill that passed the state Senate^[각주:35], the House could well strip it out before^[각주:36] the governor, Rick Snyder, signs the bill, according to Mr Shirkey. To hurry Mr Snyder along^[각주:37], the state Senate also passed a budget which would suspend the salaries of^[각주:38] top health officials if the Medicaid reforms are not speedy enough. 

The plans seem likely to reduce the number of beneficiaries^[각주:39]. Kentucky estimates that its rolls will shrink by 15%^[각주:40]. Michigan's legislative research staff^[각주:41] suggest similar effects. But state bureaucracies will have to spend dizzying sums to^[각주:42] create the infrastructure to monitor how much work people do. Kentucky will pay $374m to launch the plan - a higher cost than simply keeping the original one. Asked about the cost savings^[각주:43], Matt Bevin, the governor, said that he did not know, "nor do I care". Saving money "wasn't the intent" of the Michigan proposal either, says Mr Shirkey. 

Americans on Medicaid are not merely poor. They are profoundly poor^[각주:44]. Even after Obamacare's expansion^[각주:45], a family of three would have to make less than $28,676 a year to qualify^[각주:46]. The Brays, living in Ypsilanti^[각주:47], Michigan with their seven-year-old daughter, are one such family. Both are self-employed^[각주:48] - Mr Bray as a metalworker^[각주:49] and Mrs Bray as a weaver^[각주:50], primarily of^[각주:51] baby wraps. The pending reform^[각주:52] has left them worried. "I really have no idea how they are going to expect self-employed people to validate their hours^[각주:53]. Are we exempt^[각주:54] or are we excluded from Medicaid?" says Mrs Bray. "It would either be a lot of paperwork^[각주:55], or I would lose health care."

1. waiver ; 1. (법률) (당연한 권리·이익 등의) 고의적 포기, 임의(任意)의 포기 ; 그것을 표시하는 문서. ;; 미국∙영국 [|weɪvə(r)] [본문으로]
2. acutely ; 2. 몹시(불쾌한 감정이 매우 강함을 나타낼 때 씀) ;; 미국∙영국 [ə|kju:tli] [본문으로]
3. loaf ; [자동사] 빈둥거리다; 놀고 지내다(about, (a)round). [본문으로]
4. set[establish] requirements ; 요구 (사항)[필요 조건]을 정하다. [본문으로]
5. food assistance ; 식량 지원 [본문으로]
6. memorandum ; 4. [법] (거래의) 적요(摘要); (조합의) 규약, (회사의) 정관(定款) ;; 5. (외교상의) 각서 [본문으로]
7. attain ; 1. (목적·희망 따위를) 성취하다, 달성하다(accomplish, achieve). ;; 2. (꼭대기·고령 따위에) 도달하다, 이르다(reach). [본문으로]
8. take up ; 7. (제의 등을) 받아들이다 [본문으로]
9. impetus ; 1. [U , sing.] ~ (for sth) | ~ (to sth/to do sth) (일의 추진에 필요한) 자극(제)[추동력] ;; 미국∙영국 [|ɪmpɪtəs] [본문으로]
10. moral ; 2. [명사 앞에만 씀] 도의상의, 도의[도덕]적인 ;; 3. 도덕적으로 옳은, 도덕적인 ;; 참고 ; amoral, immoral [본문으로]
11. deserving ; [형용사] ~ (of sth) (격식) (도움・보답・칭찬 등을) 받을 만한[자격이 있는] [본문으로]
12. sort ; 1. …을 분류하다, 구분하다; …을 선별하다(out). ;; 2. …을 (특정 계급·집단 따위로) 가르다; 〔사람들〕을 (…으로) 갈라놓다. [본문으로]
13. chaff ; [U] 1. 왕겨(husks of grain) ;; 4. 하찮은 것, 쓰레기(rubbish) ;; 미국식 [tʃǽf, tʃɑ́ːf] 영국식 [tʃɑ́ːf] [본문으로]
14. exempt ; [타동사][VN] ~ sb/sth (from sth) (격식) 면제하다[받다] [본문으로]
15. undergo ; 경험하다, 겪다, 당하다(suffer); 견디다, 참다(endure) [본문으로]
16. benefit ; 2. [U , C] (英) (정부가 실업자・장애인 등에게 주는) 수당[보조금] ;; 참고 ; child benefit, housing benefit, sickness benefit [본문으로]
17. coverage ; [UC/] 1. 적용 범위 ;; 2. (보험) 보상 (범위) [본문으로]
18. portion ; 1. 일부, 부분(part), 구성 부분(constituent part). [본문으로]
19. threshold ; 2. 한계점 [본문으로]
20. disproportionately ; [부사] 불균형적으로, 불균형하게, 어울리지 않게. [본문으로]
21. qualify ; [자동사] 1. 자격을 얻다, 유자격자가 되다, 적임임을 보이다; 검정을 받다, 면허[인가]를 받다 ((as, for, in)) [본문으로]
22. better-off ; [형용사] (경제적으로) 부유한, 보다 유복한. *well-off의 비교급. [본문으로]
23. exempt ; [형용사] 면제된, 벗어난(exempted, released, free) (from). [본문으로]
24. outpost ; 1. [군사] 전초; 전초 부대[기지]; 주둔 기지 ;; 2. 변경(邊境)의 식민지[거류지] [본문으로]
25. curry favor with ; 비위를 맞추다, 빌붙다 [본문으로]
26. constituent ; 1. (특정 선거구에 사는) 주민[유권자] ;; 미국식 [kən|stɪtʃuənt] 영국식 [kən|stɪtjuənt] [본문으로]
27. outright ; [명사 앞에만 씀] 1. 완전한, 전면적인 ;; 2. 노골적인, 명백한 [본문으로]
28. animus ; 1. 악의, 원한, 적의(grudge, animosity). ;; 2. (법률) 의향, 의사(intention). ;; 3. 용기를 북돋우는 힘(an animating force). ;; [ORIGIN] Latin, soul, mind, disposition, passion ;; 미국∙영국 [|ӕnɪməs] [본문으로]
29. state senator ; a member of a state senate [본문으로]
30. legislation ; 1. [U] 법률 제정, 입법. ;; 2. [집합적] (제정된) 법률, 법규, 입법 조치. [본문으로]
31. antipathy ; [UC/](pl. -thies) 1. 반감, 혐오(opp. sympathy) ;; 2. (본능적으로) 몹시 싫은 일[것] ;; 미국∙영국 [ӕn|tɪpəθi] [본문으로]
32. undeserving ; [형용사] ~ (of sth) (격식) (…을) 가질[받을] 자격이 없는 [본문으로]
33. costly ; (cost・lier , cost・li・est), (more costly와 most costly도 씀.) 1. 많은 돈[비용]이 드는 ;; 2. 대가[희생]가 큰 [본문으로]
34. provision ; 4. [C] (법률 관련 문서의) 조항[규정/단서] [본문으로]
35. the state senate ; [미국] 주(州)의 상원. [본문으로]
36. strip (sth) out ; to completely remove things you do not want; to remove everything from a place and leave it empty [본문으로]
37. hurry sth/sb along ; to do or say something to make somebody move or work faster; to do something to make something happen faster [본문으로]
38. suspend ; 2-a. <활동·지불·영업 등을> (일시) 중지하다; 통하지 않게 하다 ;; 2-b. <판단·결정·형벌 등을> 잠시 보류하다, 일시 정지시키다, 연기하다 ;; 동의어 ; delay [본문으로]
39. beneficiary ; (pl. -aries) 1. 수익자(受益者); [법] 신탁 수익자; (연금·보험금·유산 등의) 수혜인 [본문으로]
40. shrink ; [자동사] 2. (수량·가치 등이) 감소하다(lessen). [본문으로]
41. legislative ; 법률을 제정하는, 입법상의; 입법권이 있는, 입법부의(cf. JUDICIAL, EXECUTIVE) ;; [ADJ] Legislative means involving or relating to the process of making and passing laws. ;; 미국식 [|ledƷɪsleɪtɪv] 영국식 [|ledƷɪslətɪv] [본문으로]
42. dizzy ; [형용사] 어지럽게 만드는, 어지러운, 아찔한 ;; giddy [본문으로]
43. cost saving ; [명사] 원가절약, 원가절감 [본문으로]
44. profoundly ; 깊게, 심오하게; 심원(深遠)하게; 간절히, 대단히 [본문으로]
45. expansion ; 1. [U] 확장; [비유] 발전(development) ((of)); 확대(enlargement); [상업] 거래의 확장; [미] 영토 확장 [본문으로]
46. qualify ; [자동사] 1. 자격을 얻다, 유자격자가 되다, 적임임을 보이다; 검정을 받다, 면허[인가]를 받다 ((as, for, in)) [본문으로]
47. Ypsilanti ; 2. 미국 Michigan 주 동남부, Detroit 서쪽에 있는 도시. [본문으로]
48. self-employed ; [형용사] (회사 등에 매여 있지 않고) 독자적으로 일을 하는, 자영업을 하는 [본문으로]
49. metalworker ; [명사] 금속 세공인[직공], 금속공 ;; 금속 노동자, 금속 사업장에서 일하는 노동자 [본문으로]
50. weaver ; [명사] 베 짜는[길쌈하는] 사람, 직공, 방직공 [본문으로]
51. primarily ; 1. 첫째로, 최초에, 주로(chiefly, first of all). ;; 2. 우선(in the first instance), 처음에는, 본래는, 원래(originally). [본문으로]
52. pending ; (격식) 1. 미결[미정]인, 계류 중인 ;; 2. 곧 있을, 임박한 [본문으로]
53. validate ; 1. 유효하게 하다, 확인하다(make valid, confirm). ;; 2. (법률적으로) 유효하게 하다, 합법화하다(give legal force to, legalize)(opp. invali-date). [본문으로]
54. exempt ; [명사 앞에는 안 씀] ~ (from sth) (…이) 면제되는, (…이) 없는 [본문으로]
55. paperwork ; [U] 탁상 사무, 문서 업무; 사무 절차. [본문으로]