As Republicans in Congress struggle to write a massive bill that would slash government spending and extend a bevy of tax cuts from President Donald Trump’s first term, one gargantuan point of contention looms above all others: whether to cut funding for Medicaid—and by how much. One potential avenue for reducing spending on the health care benefit program for low-income Americans that is popular among Republicans is instituting more stringent work requirements for certain recipients. While hardly a novel solution—or an exclusively partisan one—the potential imposition of such barriers has made for an uneasy debate on Capitol Hill.
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.
However, results from a brief effort to attach work requirements to Medicaid in Arkansas several years ago indicate that attempting to install a similar program on a federal level would have several complications and could result in millions of people losing their health benefits.
“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.
Moreover, given that the majority of adult Medicaid recipients are employed, some experts argue that additional work requirements would be redundant. According to the Kaiser Family Foundation, 64 percent of adults who receive Medicaid are already working on a full-time or part-time basis; 29 percent do not work because they are acting as caregivers, have an illness or disability, or are students. Only 8 percent reported that they are retired, are unable to find work, or do not have a job for some other reason.
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.)
A better case study for the implications of a national work requirement to Medicaid lies several hundred miles west of the Peach State. During the first Trump administration, Arkansas briefly implemented work and reporting requirements with the approval of the White House. During the roughly nine months that it was in place—and before it was halted by a federal judge—more than 18,000 people lost their Medicaid coverage. One 2019 survey found that many of the adults aged 30 through 49 who had lost their health benefits during that time experienced significant adverse effects, including problems paying off medical debts, inability to afford medication, and delaying medical care because of cost. Perhaps most critically, the implementation did not lead to gains in employment.
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.”
“Arkansas is not the worst-case scenario,” Sommers said. “A blanket policy across all states without state flexibility, and that requires something like what Arkansas did, is likely to be even more damaging and more destructive, because a lot of states don’t have the data infrastructure that Arkansas had. A lot of them don’t have the outreach efforts in place, and I think we would see even much larger coverage losses.”
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.
“It’s still having the same impact, in terms of people not accessing care if they’re not meeting these arbitrary requirements,” argued Harker.
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.
“If there’s a federal Medicaid work requirement, it’s not clear that these waivers would be in compliance with that because states would have to meet the rules of that federal legislation. So they might not be able to provide certain exemptions or implement their programs in the way that they want,” said Michael Karpman, principal research associate in the Health Policy Division at the Urban Institute.
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.
If Congress does implement a one-size-fits-all approach to work requirements, it may look something like a bill that was approved in the House two years ago. In 2023, the House passed the Limit, Save, Grow Act, which included work requirements for Medicaid similar to what was briefly implemented in Arkansas but did not include any clear exemptions for which eligible groups—for example, recipients with disabilities—could be excluded from the requirements. In 2023, the Congressional Budget Office estimated that the measure would save $109 billion over 10 years—far short of the cuts Republicans are currently contemplating.
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.
The Limit, Save, Grow Act would have also withheld federal funding for enrollees who did not meet the work requirements within three months for the remainder of the calendar year. “The states would be faced with the choice of either disenrolling those people from Medicaid or maintaining their coverage exclusively with state funds, and that would present a very serious dilemma for states, especially in the face of the fiscal constraints that they’re operating under,” Karpman said.
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.
Matthew Fiedler, a senior fellow at the Brookings Institution, noted in the briefing with reporters that Arkansas and Georgia had recognized some of the shortfalls with their programs; in its proposal to the Trump administration to renew its work requirements, for example, Georgia is seeking new exemptions for certain parents and changing its reporting requirement from a monthly to an annual basis.
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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