Gresham v. Azar

Originally, Medicaid provided healthcare coverage to the disabled, the blind, the elderly, and needy families with dependent children. In 2010, Congress expanded Medicaid’s coverage to low-income adults who did not previously qualify. States could choose whether to expand Medicaid to cover the new population. Medicaid established certain minimum coverage requirements that states had to include in their plans. States could deviate from the requirements if the Secretary of Health and Human Services (the secretary) (defendant) waived the requirements so that the state could engage in experimental, pilot, or demonstration projects. In 2014, Arkansas expanded Medicaid coverage to the new population of low-income adults. In 2013, Arkansas gained approval for its Medicaid demonstration waiver and in 2016, introduced the Arkansas Works program. The program encouraged Medicaid enrollees to seek employment by offering voluntary referrals to the Arkansas Department of Workforce Services. To increase participation in the program, Arkansas introduced a new version of Arkansas Works that required beneficiaries aged 19 to 49 to work or engage in educational, job training, or job search activities for at least 80 hours per month. Certain categories of beneficiaries were exempted from the hour requirement, such as pregnant women and full-time students. Nonexempt beneficiaries that failed to meet the requirements for three months during a plan year were disenrolled. The secretary approved the new Arkansas Works program requirements under the label of community engagement, finding that they would improve health outcomes, address behavioral and social factors that influence health outcomes, and incentivize beneficiaries to improve their health and achieve better health outcomes. In 2018, Charles Gresham and nine other Arkansans (plaintiffs) filed an action in district court for declaratory and injunctive relief against the secretary. The district court entered a judgment vacating the secretary’s approval of the new Arkansas Works program requirements. The district court found that the objective of Medicaid was to furnish medical assistance to those who could not afford it and that the Arkansas Works requirements’ focus on health was no substitute for providing free or low-cost health coverage. The secretary appealed.