Updated Jan 24, 2024 - Health

GOP-led states revive push for Medicaid work rules as election nears

Illustration of briefcases forming a brick wall in front of a giant red cross.

Illustration: Shoshana Gordon/Axios

Republican-controlled states are making a fresh push to tie employment to Medicaid eligibility ahead of a presidential election that could usher in a new administration receptive to the idea.

Why it matters: Rules requiring some low-income adults to work, attend school or volunteer as a condition of coverage could force more people off the Medicaid rolls at a time when millions have been dropped from the program following the expiration of pandemic-era coverage protections.

  • While the Biden administration largely reversed the Trump administration's first-ever approvals of work rules, the policy is expected to get new life under a future Republican administration.

What they're saying: "The assumption is that this wouldn't become a live option unless there was a change in administrations," said South Dakota state Rep. Tony Venhuizen, a Republican who's sponsoring a bill that would let voters this November decide if the state should consider Medicaid work requirements.

  • "It could be an option next year, it could be another four years," he told Axios.

State of play: Interest in Medicaid work rules in recent years has been chilled by the Biden administration's broad opposition to the idea, legal setbacks and rules that effectively barred states from cutting Medicaid enrollment during the pandemic.

  • But besides South Dakota, several other states have taken steps to pursue work rules in the past few months.
  • In Idaho, which originally sought a work requirement in 2019, Gov. Brad Little's new budget again calls for Medicaid work rules. Lawmakers this week also introduced a bill that would effectively block the Affordable Care Act's Medicaid expansion in the state unless it implements work rules.
  • Louisiana's new Republican governor, Jeff Landry, is reportedly considering adding Medicaid work requirements.
  • Kansas Gov. Laura Kelly, a Democrat, has proposed work rules to entice Republican lawmakers into supporting the ACA Medicaid expansion. However, Republican lawmakers rejected the idea last month, questioning if the federal government would support work rules.

Context: Republicans, who have long supported work rules, say they encourage employment and help control Medicaid spending.

  • Critics of Medicaid work rules point out that most adults with Medicaid coverage already work, and they argue the requirements come with red tape that can make it difficult for eligible people to get coverage.
  • More than 3 in 5 nondisabled, working-age adults enrolled in Medicaid worked in 2021, while another 20% reported not working because they were in school or were caregivers, according to KFF.

During the Trump administration, 13 states received approval for work rules, and several others sought permission, according to KFF.

  • Some approvals were struck down by courts on procedural grounds. The Biden administration pulled other state plans, arguing that the requirements are counter to Medicaid's overall objectives to provide health coverage.
  • When Arkansas became the first state to implement work requirements in 2018, about 18,000 adults temporarily lost Medicaid coverage before a judge halted the program. The short-lived requirement did not increase employment in Arkansas.
  • Georgia is currently the only state with a Medicaid work requirement after a federal judge allowed a Trump-approved waiver to move forward.
  • Just 1,800 people have enrolled in the first four months of a state program that, compared with the ACA, narrowly expands coverage to low-income adults who can prove they meet the work requirement.

What we're watching: Should Republicans win full control of Washington this fall, there could also be a national push for Medicaid work requirements. Republican leaders in Congress last year tried to attach work rules to must-pass legislation lifting the debt ceiling.

  • "If a Republican is in the White House, I certainly expect this issue to come roaring back," said Joan Alker, executive director of the Georgetown Center for Children and Families.
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