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"This is going to go to court the minute the first approval comes out," predicted Matt Salo, executive director of the National Association of Medicaid Directors.
The idea of conditioning government benefits on work activities was cemented into welfare more than two decades ago, when a system of unlimited cash assistance was replaced by the Temporary Assistance for Needy Families with its work requirements and time limits.
The link between government help and work later was extended to anti-hunger efforts through the Supplemental Nutrition Assistance Program, as food stamps are now called.
But most health policy experts, including a few noted conservatives, have regarded the government insurance enabling millions of people to afford medical care as a right that should not hinge on individuals compliance with other rules.
To get around this, the 10-page letter argues that working promotes good health and repeatedly asserts that the change fits within the programs objectives.
The guidance cites research that it says demonstrates people who work tend to have higher incomes associated with longer life spans, while those who are unemployed are more prone to depression, poorer general health, and even death.