The fate of work requirements in Michigan remains up in the air as state looks to institute policy for second time

Michigan is the latest state to propose work requirements for some of its Medicaid beneficiaries. (Getty Images/benkrut)

After rescinding a controversial proposal to institute Medicaid work requirements over the summer, Michigan is trying again.

The state submitted the final version of its work requirement waiver to the Centers for Medicare & Medicaid Services (CMS) on Monday.

Under the final proposal, beneficiaries with income between 100% and 133% of the Federal Poverty Level (FPL)—the expansion population—would need to participate in qualifying "healthy behavior" activities for 80 hours per month after 48 months of eligibility.

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Like other states that have asked to establish work requirements, Michigan would permit several activities instead of working. Attending high school, an internship or job/vocational training, performing community service and looking for a job would also meet the requirement, as would participating in a substance use disorder treatment program.

Some beneficiaries would be newly subject to cost sharing under the amendment as well.

RELATED: Democratic lawmakers say Medicaid work requirements could force families off coverage

Medicaid work requirements have generated considerable controversy, but Michigan uniquely came under fire earlier for a provision that could have disproportionately impacted nonwhite residents.

 A prior proposal would have exempted residents of counties with high unemployment rates, which are predominantly white, from the requirement. But the exemption would not apply to the state’s largest cities, which have a higher proportion of nonwhite residents, even though many of those cities (like Detroit and Flint) also face high unemployment.

That provision was later removed, and it was not included in the final text of the bill or the resulting waiver.

Medicaid advocates nevertheless oppose the waiver because access to coverage is expected to decline. Among its fee-for-service population alone, the waiver said enrollment is expected to drop from 125,249 currently to 122,763 by 2022. (Nearly 2.3 million Michiganders receive Medicaid coverage overall.)

Michigan's proposal did not garner much support during its mandatory 30-day comment period. Only 1% of comments (PDF) received during the comment period expressed support for the bill.

This proposal comes on the heels of studies this week in JAMA Internal Medicine said work requirements would result in the disenrollment of about 2.8% of current enrollees—a group that accounted about $3.8 million of Medicaid spending last year—from the program if implemented nationwide.

RELATED: Louisiana uninsured rate cut in half due to Medicaid expansion

CMS is likely to approve Michigan’s proposal, but that doesn’t mean it won’t face additional challenges.

In June, a federal judge struck down Kentucky’s work requirement waiver because it would not fulfill the program’s goal of helping the state “furnish medical assistance to its citizens.” CMS later solicited additional comments on the policy, presumably to shore up more support for it.

A case over work requirements in Arkansas is also pending, though thousands of Arkansans could soon lose coverage.