Most coverage of KY Medicaid waiver focuses on work req. but just as important are multiple “lockouts” if you don’t pay your premium, report a change in income, or miss a paperwork deadline you are forced to be uninsured for 6 months. Too high a price to pay.

Trump administration officials, like their Kentucky counterparts, know this. In their letter approving the proposal, they previewed their defense by making the same argument they did on Thursday ― that requiring able-bodied Medicaid recipients to work would improve their health outcomes and help them become familiar with the way private health insurance works. That is why, the administration said, it was within its rights to approve Kentucky’s request as a “demonstration project.”

The Kentucky initiative also eliminates a transportation benefit, designed to get poor people to the doctor or hospital when they don’t have the means to do so. And it ends “presumptive” or “retroactive” eligibility, under which Medicaid covers bills from the past three months for people who sign up for Medicaid only after they’ve had a medical episode that landed them in the hospital.

Bevin has also made a threat that if he can’t get his way on the work requirement and other changes, he will go ahead and roll back the expansion after all. That would leave a much larger number of Kentucky residents, perhaps approaching half a million, without health insurance.

In theory, the new requirements would not affect children, the elderly, pregnant women, primary caregivers or the “medically frail,” because Kentucky’s proposal explicitly exempts them. But those categories are narrower than they might seem, experts warned Friday as they pored over the final proposal and checked it against previous versions. (Every analyst studying it has warned that their conclusions are still a little tentative.)

Anyone who does not pay their premiums or submit paperwork to show their eligibility would lose their coverage and would not be able to reapply for six months, although people who don’t pay premiums could restore coverage by completing a financial literacy course (the details of which aren’t yet clear).

But there’s very little evidence to suggest Kentucky’s overhaul will improve health outcomes, and quite a lot of evidence to suggest it will actually worsen them. Multiple studies, some of them focusing on Kentucky specifically, have shown that giving people Medicaid makes them healthier and more financially secure, which in turn makes it easier for them to find and hold on to jobs.

In the new scheme, most working-age adults in Kentucky would have to demonstrate that they have spent at least 80 hours a month working or engaged in employment-related activities, like searching for a job or performing community service. Many would also have to pay premiums, of up to $15 a month.

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