Andres De La Torre is a staff writer for Brief Policy Perspectives and a first-year MPP student.

Since the inception of the Medicaid program in the 1960s, there have been numerous attempts to limit its scope. The joint federal-state program aimed at extending health insurance coverage to low-income individuals and families imposes strict eligibility requirements in some states. The Medicaid program has always faced limitations set by administrative barriers and an unwillingness from both state and federal representatives to expand the program fully across all states. Medicaid work requirements – requiring work or volunteering as a condition for enrollment into the program – have always been a condition for some members in opposition to the program since the 1980s. However, the condition gained some major traction in the last few years as the Trump administration worked to approve various Section 1115 Demonstrations, requests for experimental program provisions that states can use to better adjust Medicaid to meet their population’s needs. Under the administration, 17 states applied for work requirements and 12 states received approval for these policies through the waivers.

Throughout the States

    Work requirements have long been shown to have an adverse effect on Medicaid enrollees’ health, dissuading potential enrollees from applying, and acting as a barrier for health coverage. In Arkansas, more than 18,000 people lost coverage over the course of ten months after the state implemented work requirements, leading a federal judge to overturn the policy in March 2019. Similarly, it was estimated that nearly 17,000 people would have lost coverage in New Hampshire had the state gone through with their work requirements (their waiver was approved, but the implementation of the policy was paused, and state lawmakers chose not to keep pursuing it.) 

Even if enrollees do meet these work requirements, they are often still at risk of losing their coverage. Understaffed Medicaid call centers, renewals through physical mail and verification of work hours each month can make it complicated and burdensome for enrollees to stay on their coverage despite meeting requirements. In Arkansas, half of the population reported the work requirements as confusing and not being sure if the policy applied to them. 

In June 2018, Arkansas became the first state to implement work requirements for their Medicaid population, leaving the policy in place before pausing it ten months in. Furthermore, they have been the only state to disenroll people from Medicaid because of added work requirements. Arkansas required adults ages 30-49 to work 20 hours a week, participate in community engagement activities, or qualify for an exception else they lose coverage. A federal judge had put the policy on hold by April 2019, with 18,000 adults having already lost their coverage. Since then, studies have found that these work requirements not only dropped thousands of people off their coverage, but also did not increase employment among enrollees and those that lost coverage reported adverse consequences such as financial instability with medical debt, delayed care because of costs, and an inability to afford prescription drugs.

Arkansas differs from every other state with their work requirements in that they actually took away people’s coverage while states like New Hampshire and Michigan, which had approved work requirement waivers, put a pause on their policy right before they actually had to take away coverage. Utah also enacted work requirements but stopped the program three months in as the COVID-19 pandemic began to unfold. Since then, the state has opted for less restrictive reform to their program, implementing cost-sharing for Medicaid enrollees, which also has been shown to reduce access to health coverage. 

In Missouri, there are ongoing attempts by the state legislature to add work requirements for coverage under Medicaid expansion. In October 2021, Missouri’s Medicaid expansion went into effect after voters expanded eligibility through a 2020 ballot initiative titled Amendment 2. However, recently introduced bill HJR117 would propose a constitutional amendment to allow for work requirements, requiring at least 80 hours a month of work, job training or community service. The proposal would also subject portions of the Medicaid program not mandated by federal law to appropriation, essentially leaving lawmakers to decide eligibility. HJR117 has passed the Missouri House and is currently up for debate as the Missouri legislative session continues.

Response from the Biden Administration

    During his first week of office, President Biden signed an executive order requesting a review of Medicaid work requirements, and since then, has sent letters to every state with work requirement waivers stating they will be rescinded under this administration. The Centers for Medicare & Medicaid Services (CMS) has moved to revoke many of the approved work requirement waivers by the Trump administration in Arizona, Ohio, South Carolina, Indiana, and Wisconsin. The most recent developments came in December 2021 as the Biden administration rescinded a waiver in Georgia which would have implemented work requirements. The proposal, titled Georgia Pathways, would have expanded Medicaid in the state alongside adding work requirements; advocates say that while full expansion of Medicaid would have extended coverage to 678,000 people, added work requirements would have lowered the potential number of enrollees to only just 50,000. The Centers for Medicare & Medicaid Services sent a letter to Georgia reaffirming the Biden administration’s efforts to reduce health disparities by ridding the nation of work requirements. Since then, Governor Brian Kemp of Georgia has filed a lawsuit against CMS and the Biden administration in response to their decision. While the lawsuit is ongoing, the changing decisions between administrations could hurt the scope and effectiveness of demonstration waivers. 

    Since taking office, the Biden administration has made it clear that they will stop all attempts to introduce work requirements into the Medicaid program. While states continue to push back against the administration’s decision, it will be interesting to see the next steps the Biden administration takes to, steps that will address low-income people’s access to health insurance.