Kentucky got the green light from the federal government Friday to require people who get Medicaid to work. It’s a big change from the Obama administration, which rejected overtures from states that wanted to add a work requirement.

Medicaid’s chief federal officer is Seema Verma; her home state of Indiana submitted plans for a work requirement last year, and the approval letter could come any day now. Under the proposal, people would have to average 20 hours a week of work or another qualifying activity — such as volunteering or getting an education — to get Medicaid.

The goal is to increase employment among Medicaid recipients. But Sara Rosenbaum, a professor of health law and policy at George Washington University, says there’s a problem with that — most people on Medicaid are already working, or looking for work. Or they’re caring for a child or family member, or they’re sick or disabled.

Many of those people would be exempt from a work requirement, and states could also make some allowances for people battling addiction. When you consider all those exemptions, says Rosenbaum, “There is this very, very tiny slice of [of the population] who can work and simply choose not to work and apply for public assistance.”

And even if states create programs that help people find jobs, and provide things like childcare and transportation, Rosenbaum says, there’s no evidence that they would lead to more employment. And those programs are expensive.

“If you do a work program, it costs real money,” she says, “and the federal government has said, ‘we won’t pay any of those costs.’ “

What’s more likely, Rosenbaum says, is that states will basically say, ‘Get a job on your own, or get off Medicaid.’ “

And what that does, she says, is create a hurdle for everybody on Medicaid. People who are working are going to have to prove they are employed, so even people with jobs could stand to lose their insurance because of red tape. In fact, the state of Indiana’s own projections show that with a work requirement, Medicaid will cover fewer people and cost more.

Adam Mueller is an attorney at Indiana Legal Services, which helps people navigate that state’s Medicaid program. He says people already lose coverage because the program can be confusing, and there are administrative errors.

“Somewhere along the way, paperwork gets lost; there’s a miscommunication,” he says, “Folks have sometimes had difficulty proving something as easy as residency.”

And people on Medicaid often deal with crises – they may move a lot, or change phone numbers, which makes it hard to keep track of paperwork. Adding a work requirement on top of all that, Mueller says, would make staying enrolled even harder.

“There are a lot of things that can trip folks up, and that could lead to falling through the cracks,” he says.

Judith Solomon, of the Center for Budget and Policy Priorities, points out that expanded Medicaid helps some employers, too.

“We have an economic structure where there are people whose employment doesn’t provide health care,” she says.

If employees lose Medicaid, get sick and can’t make it to work, she says that’s bad for business.

Verma told reporters during a conference call Thursday that the requirement is supposed to help people.

“People moving off of Medicaid is a good outcome,” she said, “because we hope that that means they do not need the program anymore, that they have transitioned to a job that provides health insurance or that they can afford insurance on their own. This policy helps people achieve the American dream.”

But advocates say the main purpose of Medicaid is to provide health insurance, not increase employment. And until now, the federal government agreed.

Susan Jo Thomas heads Covering Kids and Families of Indiana, which advocates for health coverage in the state. Under Medicaid’s new management, she says, the philosophy surrounding work requirements has changed.

“I don’t know if it jibes with my view of Medicaid, but my view of Medicaid now is irrelevant,” she says. “It’s what Seema Verma and the administration and the folks who are at CMS decide.”

Thomas says she is taking more of a wait and see approach — the details of the work requirement have yet to be ironed out. She says if too many people lose insurance, she’ll be raising concerns with the state.

This story is part of NPR’s reporting partnership with Side Effects Public Media, WFYI and Kaiser Health News.

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Poor residents in Kentucky will have to work or do volunteer work if they want to keep their Medicaid benefits after the Trump administration on Friday approved the state’s request to add the requirements to its Medicaid program.

The new requirements apply only to “able-bodied” adults who get their health insurance through Medicaid, the federal-state health insurance program for the poor. People with disabilities, children, pregnant women and the elderly are exempt from the requirement.

“Kentucky is leading the nation in this reform in ways that are now being replicated all over the nation,” said Kentucky Governor Matt Bevin, in announcing the plan’s approval.

Kentucky’s program was approved a day after the federal Centers for Medicare and Medicaid Services announced it would look favorably on proposals from state to require poor Medicaid beneficiaries to work, go to school, get job training or do volunteer work to earn health coverage.

Nine other states — Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, North Carolina, Utah and Wisconsin — have asked CMS to allow them to add “community engagement” requirements to their Medicaid programs.

CMS Administrator Seema Verma says the work requirement option is designed improve people’s financial status and health outcomes.

In addition to the work requirement, some of Kentucky’s Medicaid beneficiaries will have to begin paying premiums for their coverage and will have to meet certain milestones to earn dental and vision care.

Before Verma joined CMS she was a private consultant and an architect of the Kentucky plan that was approved Friday.

It’s not clear how many people would be affected by the new rules in Kentucky and elsewhere.

A study by the Kaiser Family Foundation found that about 60 percent of “able-bodied” Medicaid beneficiaries already work. And a third of those who don’t have jobs say it’s because they are ill or disabled.

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Dr. Mahendra Patel, a pediatric cancer doctor, has begun giving away medications to some of his young patients, determined not to disrupt their treatments for serious illnesses like leukemia. He’s worried Congress will fail to renew funding soon for a health program that pays for the care of millions of children across the country.

In his 35 years of practice, Patel, of San Antonio, has seen the lengths to which parents will go for their critically ill children. He has seen couples divorce just to qualify for Medicaid coverage, something he fears will happen if the Children’s Health Insurance Program is axed. “They are looking at you and begging for their child’s life,” he said.

The months-long failure on Capitol Hill to pass a long-term extension to CHIP, which provides health coverage to 9 million lower-income children, portends serious health consequences for many of them.

About 1.7 million children in 20 states and the District of Columbia could be at risk of losing their CHIP coverage in February because of the funding shortfall, according to a report released Wednesday by the Georgetown University Center for Children and Families.

Treatment plans for serious diseases can span months, leaving some doctors, like Patel, to jury-rig solutions in case CHIP falls through. The challenges are particularly great for kids with chronic or ongoing illnesses like asthma or cancer.

Dr. Joanne Hilden, a pediatric cancer physician in Aurora, Colo., and past president of the American Society of Hematology-Oncology, said the families of cancer patients who depend on CHIP are in a difficult position because they can’t schedule care to be finished before program funding runs out.

A San Antonio pediatrician, Dr. Carmen Garza, is advising parents to be sure to keep their children’s asthma medications and other prescriptions current and to fill any refills they can so that they have vital medicines if CHIP expires.

Federal funding for CHIP originally expired Oct. 1. In December, Congress provided $2.85 billion to temporarily fund the program. That money was supposed to help states get through at least March, but it’s coming up short.

The Centers for Medicare & Medicaid Services last week said it couldn’t guarantee funding to all states past Jan. 19.

A few states, including Louisiana and Colorado, plan to use state funds to make up for the lack of federal money. It’s a drastic step, since the federal government pays, on average, nearly 90 percent of CHIP costs.

Most states can’t afford to make up the difference and will have to freeze enrollment or terminate coverage when their federal funding runs dry. Virginia and Connecticut, for instance, can promise to keep their CHIP program running only through February, officials said.

The largest states seem to be in the best shape, though even they can guarantee only a few months of care. Florida, California and Texas officials said they have enough CHIP funding to last through March. New York officials said they have enough money to last until at least mid-March.

Before Congress passed the short-term funding fix in late December, CHIP programs survived on the states’unspent funds and a $3 billion pool of CHIP money controlled by CMS.

Republicans and Democrats on Capitol Hill say they want to continue CHIP, but they have been unable to agree on how to fund it. The House plan includes a controversial provision — opposed by Democrats — that takes millions of dollars from the Affordable Care Act’s Prevention and Public Health Fund and increases Medicare premiums for some higher-earning beneficiaries.

The Senate Finance Committee reached an agreement to extend the program for five years but didn’t unite on a funding plan.

But two key Republican lawmakers — Sen. John Cornyn of Texas, who is part of the Senate leadership, and Rep. Greg Walden of Oregon, who chairs the House Energy and Commerce Committee — told reporters Wednesday that they think an agreement is close.

Alabama and Utah are among the states unsure how long their federal CHIP funding will last, according to interviews with state officials. Part of the problem is they haven’t been told by CMS how it will disburse money from the agency’s so-called redistribution pool. Under the pool’s restrictions, states with extra money would have to give it to states that are running low.

Although hospitals, doctor groups and child health advocates have been sounding the alarm about CHIP for months, the Trump administration has kept quiet, saying only that it’s up to Congress to renew the program.

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Without CHIP, dental hygienist Marina Natali says she couldn’t afford health coverage for her sons, 15-year-old Marcus (left) and 12-year-old Ciro. When Ciro broke his arm ice-skating last year, CHIP covered his medical bills.

Courtesy of Marina Natali

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Courtesy of Marina Natali

When Marina Natali’s younger son broke his arm ice-skating in 2017, she didn’t have to worry about paying for so much as a doctor’s visit: CHIP footed all the medical bills.

If that accident happened later this year, though, Natali, 50, of Aliquippa, Pa., might be scrambling. She can’t afford private coverage for her two children on her dental hygienist pay.

“It’s creating a lot of anxiety about not having insurance and the kids getting sick,” she said.

Dr. Todd Wolynn, a Pittsburgh pediatrician, said families are reacting with “fear and disbelief” to CHIP’s uncertain future. The group practice hasn’t changed any scheduling for CHIP patients, but he said “families are terrified” about the coverage disappearing.

Pennsylvania officials notified CHIP providers in late December — who then informed enrollees — that the state would have to end the program in March unless Congress acts.

“These families don’t know if the rug is being pulled out from them at any time,” he said.

Dr. Dipesh Navsaria, a Madison, Wis., pediatrician and vice president of the state’s chapter of the American Academy of Pediatrics, worries that many parents will be surprised if their children are suddenly without coverage. They may not know that the state-branded programs they use, such as BadgerCare Plus in Wisconsin, Healthy Kids in Florida and All Kids in Alabama, are all part of CHIP.

Ariel Haughton of Pittsburgh said she’s upset her federal lawmakers have left CHIP in flux for her two children and millions of kids around the country. “They seem so cavalier about it,” she said.

If Pennsylvania cancels CHIP, she likely won’t bring Javier, 2, for his two-year checkup unless there’s something clearly wrong with him. “We will have to decide between their health and spending the money on something else,” she said.

Kaiser Health Newsis a nonprofit news service covering health issues. It is an editorially independent program of theKaiser Family Foundation that is not affiliated with Kaiser Permanente.

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Updated at 11:29 a.m. ET

The Trump administration is encouraging states to require “able-bodied” Medicaid recipients to work or volunteer in order to keep their health insurance coverage.

On Thursday, the Centers for Medicare & Medicaid Services, which is part of the Department of Health and Human Services, issued new guidelines for states that want some adults to work in exchange for the health insurance coverage.

Under the rules, states can require Medicaid beneficiaries to work, volunteer or participate in job training. People who are elderly or disabled, and pregnant women and children, would be excluded.

CMS Administrator Seema Verma said on Twitter that the new efforts will “improve Medicaid enrollee health outcomes by incentivizing community engagement.”

“This is about helping people rise out of poverty,” Verma said Thursday in a conference call with reporters.

She cited studies that show a correlation between good health and having a job.

But opponents to tying Medicaid to work argue that good health leads to the ability to hold down a job.

“Access to Medicaid makes it easier for people to look for work and obtain employment,” says Suzanne Wikle of the Center for Law and Social Policy. “A so-called work requirement does not support work but instead puts a critical support for work at risk.”

Ten states — Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin — have already filed applications with CMS to add work requirements to their Medicaid programs.

But it’s not clear how many people would be affected by the new rules. A study in December in JAMA Internal Medicine found that about half of the Medicaid recipients in Michigan were already working.

In addition, people who are disabled under the Americans with Disabilities Act but have Medicaid benefits for another reason could be exempted, or the state would be required to make “reasonable modifications” such as a reduced hourly requirement to ensure that the requirements don’t disproportionately hurt people with disabilities.

And states are also required to make such accommodations for people with addiction to opioids and other substances. That could mean counting time spent in drug treatment as a form of “community engagement.”

The range of community engagement requirements can be quite broad, according to the CMS guidelines sent to states on Thursday. In addition to traditional work and job training, engagement could include caring for a child or elderly parent, seeking treatment for drug addiction or going to school.

Verma said the agency wants to give states as much latitude as possible to try out their own ideas.

“There are a lot of different ideas, and a lot of ways to go about this,” she said. “We want to give states as much flexibility as possible because that’s where we’ll be able to evaluate what actually works best.”

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A Twitter battle over the size of each “nuclear button” possessed by President Trump and North Korea’s Kim Jong Un has triggered a surge in sales of a drug that protects against radiation poisoning.

Troy Jones, who runs the website www.nukepills.com, said demand for potassium iodide soared last week, after Trump tweeted that he had a “much bigger & more powerful” button than Kim – a statement that raised new fears about an escalating threat of nuclear war.

“On Jan. 2, I basically got in a month’s supply of potassium iodide and I sold out in 48 hours,” said Jones, 53, who is a top distributor of the drug in the United States. His Mooresville, N.C., company sells all three types of the over-the-counter product approved by the Food and Drug Administration. No prescription is required.

In that two-day period, Jones said, he shipped about 140,000 doses of potassium iodide, also known as KI, which blocks the thyroid from absorbing radioactive iodine and protects against the risk of cancer. Without the tweet, he typically would have sent out about 8,400 doses to private individuals, he said.

Jones also sells to government agencies, hospitals and universities, which aren’t included in that count.

Alan Morris, president of the Williamsburg, Va.-based pharmaceutical company Anbex Inc., which distributes potassium iodide, said he has seen a bump in demand, too.

“We are a wonderful barometer of the level of anxiety in the country,” Morris said.

A spokeswoman for a third company, Recipharm AB, which sells low-dose KI tablets, declined to comment on recent sales.

Jones said this isn’t the first time in recent months that jitters over growing nuclear tensions have boosted sales of the drug, which comes in tablet and liquid form and should be taken within hours of exposure to radiation.

It’s the same substance often added to table salt to provide trace amounts of iodine that ensure proper thyroid function. Jones sells his tablets for about 65 cents each, though they’re cheaper in bulk. Morris said he sells the pills to the federal government for about a penny apiece.

Yet, neither the FDA nor the Centers for Disease Control and Prevention recommends that families stockpile potassium iodide as an antidote against nuclear emergency.

“KI (potassium iodide) cannot protect the body from radioactive elements other than radioactive iodine — if radioactive iodine is not present, taking KI is not protective and could cause harm,” the CDC’s website states.

The drug, which has a shelf life of up to seven years, protects against absorption of radioactive iodine into the thyroid. But that means that it protects only the thyroid, not other organs or body systems, said Dr. Anupam Kotwal, an endocrinologist speaking for the Endocrine Society.

“This is kind of mostly to protect children, people ages less than 18 and pregnant women,” Kotwal said.

States with nuclear reactors and populations within a 10-mile radius of the reactors stockpile potassium iodide to distribute in case of an emergency, according to the Nuclear Regulatory Commission. An accident involving one of those reactors is far more likely than any nuclear threat from Kim Jong Un, Anbex’s Morris said.

Still, the escalating war of words between the U.S. and North Korea has unsettled many people, Jones said. Although some of his buyers may hold what could be regarded as fringe views, many others do not.

“It’s moms and dads,” he said. “They’re worried and they find that these products exist.”

Such concern was underscored last week, when the CDC announced a briefing on the “Public Health Response to a Nuclear Detonation.” One of the planned sessions is titled “Preparing for the Unthinkable.”

Hundreds of people shared the announcement on social media, with varying degrees of alarm that it could have been inspired by the presidential tweet.

A CDC spokeswoman, however, said the briefing had been “in the works” since last spring. The agency held a similar session on nuclear disaster preparedness in 2010.

“CDC has been active in this area for several years, including back in 2011, when the Fukushima nuclear power plant was damaged during a major earthquake,” the agency’s Kathy Harben said in an email.

Indeed, Jones saw big spikes in potassium iodide sales after the Fukushima Daichii disaster, after North Korea started launching missiles — and after Trump was elected.

“I now follow his Twitter feed just to gauge the day’s sales and determine how much to stock and how many radiation emergency kits to prep for the coming week,” Jones said, adding later: “I don’t think he intended to have this kind of effect.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundationthat is not affiliated with Kaiser Permanente. Follow JoNel Aleccia on Twitter: @JoNel_Aleccia.

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Top Philadelphia officials are advocating that the city become the first in the U.S. to open a supervised injection site, where people suffering from heroin or opioid addiction could use the drugs under medical supervision.

But the controversial proposal aimed at addressing the city’s deadly drug crisis must first overcome resistance from top city police officials, community residents and the federal government.

It’s a divisive idea: People bring their own drugs to shoot up under the watch of medical staff, in a facility that provides clean needles and other equipment. Advocates say the goal is to provide a bridge to treatment.

There are about 90 such official facilities around the world. Though some U.S. cities — including Seattle, San Francisco and Denver — are talking about establishing this sort of city-sponsored site, there are none in the United States, so far.

Philadelphia may be unusually well-positioned to be the first; its opioid crisis is mostly concentrated in one neighborhood, where some of the purest, cheapest and most deadly heroin in the nation can be purchased.

The city’s new district attorney, Larry Krasner, has promised he would not prosecute users at the safe-injection site.

“Supervised injection sites are a form of harm reduction,” says Krasner, who was sworn into office just last week.

The rise in opioid deaths in Philadelphia reflects a nationwide epidemic; the size and lethality of the problem, Krasner says, should be shifting the conversation away from the country’s long history of responding to drug users with criminal punishment.

“The only way to get people to turn their lives around,” he says, “is to keep them alive long enough so they can do that. And we’re going to do that.”

Philadelphia’s Mayor, Jim Kenney, says he soon will make a public announcement on the topic of establishing a supervised injection site — but, so far, he has refused to provide details.

Sources close to Kenney say he is still working to bring skeptical members of his administration and other opponents on board.

Kenney has been working on Philadelphia’s drug problem for months; first launching a task force to combat the opioid crisis, then creating a new position in city hall to coordinate so-called harm reduction initiatives.

Other plans underway include establishing rules for doctors to more safely prescribe opioids; public education campaigns aimed at combating the stigma around usage of the drugs; and ensuring that those whose overdose is reversed in an emergency room are put directly into treatment — what’s known as a “warm handoff.”

The idea of a safer place to use heroin appeals to people like Johnny, a 39-year-old electrician from Philadelphia’s suburbs. (Because he is using an illegal drug, NPR is using only his first name.)

“I would absolutely go there,” Johnny says, adding that he recently relapsed after being sober for seven years.

“Every shot — you never know what’s going to happen,” he says. “It can always be your last one.”

On his lunch breaks from work, Johnny says, he often travels to Philadelphia’s Kensington neighborhood — the epicenter of the city’s opioid crisis — to use drugs.

Recently, a sprawling open-air drug market and homeless encampment in Kensington along decommissioned train tracks was cleared out, prompting droves of opioid users to regroup in smaller pockets under bridges, in alleyways, on the streets and in abandoned buildings.

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Proponents of medically supervised, indoor sites for opioid injection say such places would be much safer than tent encampments like this one — and could help people addicted to opioids transition into treatment and away from drug use.

Natalie Piserchio for WHYY

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Natalie Piserchio for WHYY

Under one of those bridges recently, there was a row of tents. Many people live there, and some visitors, like Johnny, use the tents as a private place to do heroin.

He says he would rather inject his drugs in a medically-supervised facility, and thinks Philadelphia residents would prefer that, too.

“People are not going to be shooting up on your front stoop” he says, “or in your backyard, hiding. It will cut down on people dying in abandoned house around here — or even here.” He motions to the tents. “They come down here and get high and die here under a bridge.”

But some law enforcement officers have a different view. Philadelphia’s police commissioner, Richard Ross, has been skeptical about designating a legal place for the use of an illegal narcotic.

And even if local police can be convinced, the proposal is likely to provoke a standoff with the federal government, which has promised to aggressively crack down on similar plans in Vermont.

Patrick Trainer, a special agent with the Drug Enforcement Agency’s Philadelphia field office, says he is no fan of the model.

“The concept, for us, with safe injection sites, is just not a concept we can get behind,” Trainer says.

Such a site could attract street drug dealers and increase their sales, Trainer worries. More than that, he says, the federal government is leery about looking the other way in the face of drug use, worried about where that first step might lead.

“Is it going to stop with a safe injection site?” he asks. “Are we going to do that and then, next year and the year following, are we then going to be talking about, OK, there are still overdose deaths, so maybe we need to look into government-supplied drugs?”

Jen Bowles, a researcher now at the University of California, San Diego, who has studied opioid use in Kensington, says research in other cities has shown that safe injection sites actually decrease fatal overdoses and do not cause a spike in crime.

“There’s a tremendous fear that says, ‘If we create a space in which drug users can more safely consume drugs, that may somehow be encouraging drug use,’ ” Bowles says. “But that conflicts with the science that finds that not to be true.

Still, evidence-based studies don’t change all minds. No Kensington residents agreed to speak out publicly for this story, since the exact proposal is still being hashed out. Some, though, say the idea of a safe-injection site makes them uneasy. Winning the support of the local community will likely be another battle.

Nonetheless, the statistics are creating new urgency.

Opioids were the main driver in what officials believe were 1,200 drug overdose deaths in Philadelphia last year.

That’s four times the city’s murder rate.

Standing along the row of tents, Johnny thinks he has a good counter-argument for those troubled by the notion that opioid injections by people like him can and should be made to be safer, and that the city should play a role in making that happen.

“Someday their children could be out here using,” he says. “Wouldn’t they want their children to be in a safe environment if they’re not able to beat the disease?”

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