For most of its history, Medicaid, the joint state and federal health insurance program for people with low income, has not tied eligibility to employment. This changed during the Trump administration, which encouraged state Medicaid agencies to test work requirements. Under Trump, the Centers for Medicare and Medicaid Services (CMS) approved 11 state proposals for implementing waiver-based demonstration programs. Most of these states’ work requirement proposals were never implemented owing to court challenges, the threat of legal challenges, and the economic disruption of the COVID-19 pandemic. The Biden administration then rescinded approval of all proposals in early 2021. The future of Medicaid work requirements will, however, ultimately depend on future administrations, and preliminary evidence suggests much is on the line.
What exactly are Medicaid work requirements?
Federal and state policymakers have periodically proposed and established “community engagement” requirements — more commonly known as work requirements — for people enrolled in Medicaid. Whereas Medicaid eligibility is primarily based on income, work requirements add a new condition of eligibility for adults, making coverage contingent on working, volunteering, or engaging in educational activities for a minimum number of hours.
Which Medicaid enrollees work requirements would apply to, and how many hours of approved activities would be required, have varied across the 11 state proposals. Most of the proposals would require working-age Medicaid beneficiaries (ages 18 to 64) to prove they are doing 80 hours of work or other approved activities each month, or 20 hours per week. Many proposals — though not all — have included exemptions from work requirements for people with disabilities, pregnant people, those deemed medically frail, and caregivers of young children or family members with a disability.
What do we know about Medicaid enrollees’ employment status?
A large majority of adult Medicaid beneficiaries who can work already do. Before the COVID-19 pandemic, 62 percent of adult Medicaid beneficiaries who were not enrolled in Medicare and did not meet Social Security disability criteria were either working or in school. A 2021 analysis found that an even larger proportion of working-age adults on Medicaid, 67 percent, were either in school or working full or part time. An additional 13 percent were caregivers, and some part-time workers were also enrolled in school or work training programs.
Are Medicaid enrollees able to comply with work requirements?
Medicaid’s main objective is to provide health coverage to people with low income. Experts have raised concerns that adding work requirements to the program could cause many people to lose access to critical health services. Some believe the new policy cannot be tested safely or ethically in low-income communities because it risks participants losing coverage, which could negatively impact their health.
Because of the unique challenges they face in securing and maintaining employment, complying with work requirements can be especially difficult for Medicaid beneficiaries. Employed adults who rely on Medicaid frequently work in low-wage positions with variable hours, such as service or retail jobs, which often do not offer employer-sponsored insurance or affordable coverage. These jobs can prevent them from consistently meeting monthly requirements to work 80 hours. Low-income people are also likely to experience other barriers to employment, such as limited access to transportation, lack of internet access, caregiving responsibilities, and chronic health problems — any of which can make finding or keeping a job challenging.
Work requirements also place significant reporting burdens on Medicaid enrollees. Even those who work more than 20 hours a week risk losing their coverage if they are unable to consistently document and submit proof of the number of hours they’ve worked. Reporting work hours can be especially difficult for people with multiple jobs, people without access to the internet or a computer, and people with limited English proficiency.
What is the current status of Medicaid work requirements?
Only two states have implemented Medicaid work requirements. Arkansas, the first to do so, launched its program in June 2018 and ended it in March 2019 because of a court order. While the policy was in effect, the state required Medicaid beneficiaries ages 19 to 49 to report 80 hours of approved work or community engagement activities each month through an online portal. Failure to report hours for any three months, without an exemption, resulted in a loss of coverage for the remaining calendar year.
In July 2023, Georgia implemented its Pathways to Coverage program, which includes a Medicaid work requirement for parents and childless adults under age 65 with annual income up to 100 percent of the federal poverty level ($25,820 for a family of three in 2024). Georgia has not expanded Medicaid to adults with incomes up to 138 percent of the federal poverty level, as allowed under the Affordable Care Act, so before the Pathways program, parents in Georgia were only eligible for Medicaid if their income fell below 31 percent of the federal poverty level ($7,700 for a family of three in 2023). Nondisabled childless adults under age 65 were not eligible for the program at any income level. Pathways to Coverage therefore incrementally expands the population that is eligible for Medicaid in the state. However, to get coverage, the newly eligible populations must comply with work requirements.
Georgia’s work requirement policy is considered particularly restrictive because, unlike other state proposals to date, it does not systematically exempt populations that tend to struggle with employment, like adults with disabilities or those caring for a young child.
How have work requirements impacted Medicaid enrollees?
In Arkansas, more than 18,000 Medicaid enrollees lost coverage in the nine-month period in which the work requirement was in effect. Survey research revealed that the reporting process was a major driver of coverage losses: many Medicaid enrollees who were subject to the work requirements found the reporting process confusing or inaccessible, and nearly a third of the target population was unaware of the policy altogether. People who lost coverage reported delaying care and skipping medications because of costs, as well as incurring serious medical debt. Critically, there was no increase in employment among the target population.
In Georgia, where the work requirement only applies to people newly eligible for Medicaid, coverage gains have fallen far short of what policymakers anticipated. Six months after the rollout of Pathways to Coverage, approximately 3,500 people had enrolled in Medicaid through the program, well below the state’s first-year enrollment projection of 100,000. Georgia’s stringent requirements for documenting and reporting work hours have contributed to low enrollment numbers.
How have work requirements fared in other safety-net programs?
Other safety-net programs have had work requirements in place for more than 20 years, with only brief suspensions during economic declines and the COVID-19 pandemic. This includes the Temporary Assistance for Needy Families (TANF), which provides time-limited cash assistance to low-income families with children through federal block grants to states, and the Supplemental Nutrition Assistance Program (SNAP), a federally funded, state-administered program to subsidize food costs for people with low income. TANF and SNAP have work requirements with varying exclusions, and both are allocated federal funding for employment training and work supports, such as childcare subsidies, though evidence suggests this funding is insufficient to meet the need. CMS, on the other hand, does not allow Medicaid funding to be used for work supports.
The Congressional Budget Office has found that work requirements in TANF and SNAP have had mixed results. While work requirements in both programs have led to slight gains in employment, they have not increased average income among target populations. That’s largely because income gains that resulted from people working more have been offset by income losses from people removed from the programs for not complying with the requirements. Many people who lose SNAP or TANF benefits because of work requirements remain in poverty as they have few, if any, alternative sources of income.
What is the legal status of Medicaid work requirements?
Medicaid work requirements are legally contentious. To implement them, states must submit a proposal to CMS, whose approval depends on the current administration’s stance on the policy. While the Biden administration has made it clear it will not approve states’ work requirement proposals, governors and legislators in several states, including Arkansas, have signaled their intention to continue submitting proposals, any of which could be approved by a future administration.
Even if CMS approves a work requirement proposal, it can be delayed or overturned by litigation. Federal courts ruled against Trump administration approvals in Arkansas, Kentucky, and New Hampshire, halting implementation in Arkansas and preventing it in the other two states. The Supreme Court took up appeals from Arkansas and New Hampshire but ultimately sent the cases back to lower courts while vacating earlier decisions against work requirements in both states. As a result, there is no binding precedent, and the cases could be relitigated.
Georgia’s earlier approval under Trump was rescinded by Biden before the policy took effect, leading the state to sue the federal government. A federal court ruled in Georgia’s favor because the proposal expands coverage to a group of people not previously covered, and the state has since implemented a work requirement.
