In March, the House approved an outline for the massive tax cuts and spending bill—which is being considered through a process known as “reconciliation” to avoid a 60-vote threshold for passing most legislation in the Senate—instructing the committee that oversees Medicaid spending to cut $880 billion over 10 years. According to the nonpartisan Congressional Budget Office, most of the cuts would need to come from slashing Medicaid spending. Some Republicans have balked at the concept of cutting Medicaid, placing GOP leadership between a rock and a hard place as they write the legislation.
“The evidence is really clear that however you structure these requirements, people will lose coverage,” said Laura Harker, senior policy analyst at the left-leaning Center on Budget and Policy Priorities.
The only state that has currently implemented work requirements for Medicaid is Georgia, one of the few states that did not expand Medicaid coverage under the Affordable Care Act. But Georgia’s program differs from other proposals in that it is tied to an expansion of eligibility: In order to enroll in Medicaid, a person must provide verification of work hours. Although only a few thousand people have enrolled in Medicaid since the program was implemented, it has not resulted in anyone losing their coverage. (The Government Accountability Office, a federal nonpartisan watchdog, is currently studying the effects of the Georgia program.)
Despite efforts by the state government to inform Medicaid recipients of the new work and reporting requirements, many of the people affected had low awareness of the program. Other barriers included the bureaucratic red tape of filling out work-reporting paperwork each month. But Ben Sommers, a professor at the Harvard T.H. Chan School of Public Health, who co-authored the 2019 report, said in a briefing with reporters that Arkansas “actually did a lot of things right,” including its ultimately unsuccessful “aggressive outreach effort.”
Along with Arizona and Ohio, Arkansas submitted an official proposal this year to once again implement work requirements for Medicaid, which is pending approval. But Arkansas updated its proposal from what was implemented in 2018, attempting to make it more personalized for individuals by eliminating the monthly reporting requirement and pairing individuals with a “success coach” to develop a plan for obtaining work, although it’s not clear who these coaches would be or what the development plans would look like.
Still, the updates to the Arkansas proposal show an interest in addressing some of the issues with the 2018 implementation, namely the stringent reporting requirements. If a federal work requirement were implemented, that would reduce states’ flexibility.
This is a point that former Arkansas Governor Asa Hutchinson, who oversaw the implementation of the initial work requirements in the state, echoed in a recent opinion piece in The Hill. “Congress must allow states sufficient latitude to tailor interventions to different populations. Blanket exemptions will result in missed opportunities, but so will limitations on ways to demonstrate compliance with work requirements,” Hutchinson wrote.
A March report from the Urban Institute found that if work requirements modeled on the Limit, Save, Grow Act were fully implemented for adults aged 19 through 55 in the 40 states and Washington, D.C., where Medicaid access has been expanded, between 4.6 and 5.2 million recipients would lose their eligibility. Moreover, researchers found that at least 10,000 adults would lose coverage in every state that expanded Medicaid access, with more than 100,000 losing coverage in 13 states.
It’s far from clear what potential work requirements would actually look like—whether they would be akin to the Limit, Save, Grow Act or be more like what Arkansas is currently proposing. Some more moderate House Republicans have indicated that cuts to Medicaid are a hard line for them, and given the narrow GOP majority in the House, even a few “no” votes could sink an eventual reconciliation bill. The markup for the committee that would oversee cuts to Medicaid was postponed for later in May, signaling difficulty in reaching a consensus. Even though Speaker Mike Johnson has said that reducing “waste, fraud, and abuse” is not equivalent to “gutting Medicaid,” it’s likely that any work requirements would lead to massive disenrollment.
Fiedler contrasted this approach with that of Washington’s lawmakers: “There’s not a lot of recognition in the congressional discussion recognizing what the states are saying, because they’re essentially doubling down, or potentially even ramping up from what didn’t work the first time in those states, even as leaders in those states themselves are saying, ‘Pause, slow down,’” Fiedler said.
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