Illustration: Brendan Lynch / Axios
Republicans insist that Medicaid work requirements will only weed out people who shouldn't be on safety net program's rolls in the first place.
- The reality is that the red tape and bureaucratic hoops to jump through will have far broader effects, health policy experts say.
Why it matters: Coverage losses will be central to the reconciliation debate in the coming weeks as the Senate takes up the House-passed package containing the most significant changes to Medicaid in the program's history.
What's inside: The reconciliation bill includes a new federal requirement for those ages 19 to 64 to work or participate in 80 hours of community engagement per month to keep their Medicaid coverage.
- The requirement was supposed to kick in starting in 2029, but the House Freedom Caucus insisted the timeline be moved up to Dec. 31, 2026 — which would generate around $50 billion more in savings per year.
- The Senate still could make its own changes, though there's general support for the idea in GOP circles.
- The other side: The White House contends that 4.8 million able-bodied adults are choosing not to work and said in a Monday press release that work requirements "will strengthen the system to better help those most in need of assistance."
State of play: Most able-bodied Medicaid recipients work full or part time. Some states have already imposed work requirements, resulting in thousands of people either losing their coverage or finding it very difficult to sign up.
- Arkansas implemented a work requirement in 2018 that lasted less than a year and left 18,000 fewer people covered, or about 25% of the eligible population, per KFF. A court eventually ruled the program violated Medicaid law.
- Work requirements began in Georgia as part of a Medicaid expansion in June 2023, and as of January, only 6,500 adults had enrolled — a fraction of the 25,000 the state expected would sign up in the first year, KFF says.
- New Hampshire also tried to launch work requirements but stopped after a month, after only 8,000 of the 25,000 people subject to the requirement had complied.
The Urban Institute has estimated that up to 6 million people, or 40% of those eligible, could lose their Medicaid coverage in 2026, assuming work rules were in effect that year for expansion enrollees ages 19 to 64.
How it works: States would have to build systems to track all of the enrollees and their work status, likely adding significant costs to their program budgets.
- Then enrollees would have to contact states, which could be required as often as once a month, to show that they're working or participating in another eligible activity like caretaking.
- Enrollees would have to submit paperwork proving a disability, substance abuse disorder or other criteria to qualify for an exemption.
One concern is that the envisioned system doesn't account for informal arrangements, such as whether a person is paid in cash for domestic work, seasonal jobs in agriculture or even being self-employed.
- It also assumes that covered individuals would be aware of the work requirements and would try to comply with the administrative requirements.
What they're saying: "The experience in Arkansas was that the people who lost coverage because of the work requirements for the most part became uninsured," said Jennifer Tolbert, deputy director of the Medicaid program at KFF. "There was no increase in the share of those working."
- "In all of these states, we see time and again that the people hurt include workers who are supposed to be exempt, including people with disabilities who are supposed to be exempt," said Leonardo Cuello, a research professor at the Georgetown University Center for Children and Families.
- "At the end of the day, the goal of this proposal is to get more people working. There is no evidence in Arkansas that that happened," said Ben Sommers, a health economist at Harvard who studies work requirements.
The bottom line: Work requirements don't appear to encourage people to work, and the large savings in the reconciliation bill are likely to appear because of people losing their health coverage.
- "The argument is that this is about waste, fraud and abuse. That's not how this bill produces savings," Sommers said.
- "These are savings from kicking eligible people out of Medicaid who should have that coverage, who need it for their health care, because they can't navigate this big bureaucratic mess that the bill creates," he said.
