Trevor Hawkins, an attorney at Legal Aid of Arkansas, remembers how busy his job was when the state imposed work requirements on Medicaid recipients for a time: His office was flooded with frantic calls from people saying they couldn’t get in comply with the novel regulations because they were not fit enough to work or had to care for infirmed relatives.
“A whole lot of people got notices after a month or two saying, ‘Hey, you’re out of compliance and you’re losing your coverage,'” Hawkins told Stateline. For many people, he said, maintaining their insurance coverage is “absolutely important to maintaining their health or recovering and getting back to work.”
In June 2018, Arkansas became the first state to require some Medicaid recipients to work, volunteer, attend school or participate in job training to receive benefits. A federal judge at the time stopped politics in April 2019, 18,000 adults lost insurance coverage.
Arkansas was one of 13 states which was given permission during the last Trump administration to impose work rules on at least some Medicaid recipients. Nine other states sought permission to issue Medicaid work requirements during Trump’s term, but had not received approval by the end of the term.
When the Biden administration took office, it revoked all authorizations. But now that Trump is coming back, many of those states will try again — and they will have a supportive U.S. Congress in their corner.
Republicans are on Capitol Hill eager to find ways to fund the extension of Trump’s first-term tax cuts, and Medicaid — funded jointly by the federal government and states — is in its sights. Requiring states to adopt Medicaid work rules, as many Republicans would like to do, would cut federal spending by an estimated $109 billion over a decade. according to the Congressional Budget Office. That’s because costs for about 900,000 people would be shifted entirely to the states, while another 600,000 people would no longer be insured, CBO estimated. About 72.4 million people are enrolled in Medicaid.
Arkansas was already renewing its efforts before Trump’s victory. Last year, Republican Gov. Sarah Huckabee Sanders applied for federal approval by the Biden administration to apply work rules to able-bodied adults covered by the state’s expansion of Medicaid under the Affordable Care Act and enrolled in health plans that Arkansas Medicaid writes for them on the state’s health insurance exchange. This application is pending.
Georgia has prevailed in a legal battle with the Biden administration. Work requirements already exist for people covered by the partial expansion of Medicaid. And Idaho, Mississippi, Oklahoma, South Dakota and Tennessee have pending requests to require that at least some of their Medicaid recipients work.
meet requirements
Advocates say requiring Medicaid recipients to work, study or train for a career gives them a boost toward self-sufficiency and financial stability. Kristi Putnam, the secretary of the Arkansas Department of Human Services, said in a statement She announced her state’s latest call that she would challenge people to “take advantage of economic opportunities that can lead to real career advancement.”
“Meaningful work connects people with purpose – and through the pandemic we have seen negative impacts on mental health because people feel disconnected,” Putnam said.
But critics say such rules end up harming far more people than good. In a 2020 study In examining how work requirements affected Arkansas, researchers at the Harvard TH Chan School of Public Health “found no evidence that the policy achieved its stated goal of promoting work and instead found significant evidence of harm to health care and the access.”
More than 95% of Arkansas beneficiaries surveyed by researchers already met work requirements or should have qualified for a waiver. The main reason people lost insurance coverage, the researchers said, was because they had difficulty checking whether they were following the rules. Many of those who lost insurance coverage stopped taking their medications, delayed treatment, and fell into medical debt.
“Our results should serve as a clear warning to federal and state policymakers when considering future work requirements policies,” the researchers concluded.
Under rules Arkansas put in place during the first Trump administration, Medicaid enrollees under age 50 are eligible had to report myself that they work at least 80 hours every month, attend school, complete vocational training or do voluntary work. The rule applied only to people who became eligible after Arkansas expanded Medicaid under the ACA to adults making up to 138% of the federal poverty level. And people were exempt if they were pregnant, had a child under 18 at home, were disabled, needed to care for a person who couldn’t care for themselves, were in alcohol or drug treatment or were working full-time were in school or vocational training.
About 70,000 of the approximately 270,000 Arkansans who received Medicaid were subject to the novel rules, and about one in four of them lost coverage.
Unlike Arkansas, Georgia did not expand Medicaid under the Affordable Care Act. But it is Pathways to Coverage ProgramLaunched in July 2023, the program allows individuals with household incomes up to 100% of the federal poverty level who are not already eligible for Medicaid to enroll in the program if they meet work requirements. The qualifying activities and exemptions in Georgia are similar to those in Arkansas.
Fiona Roberts, a spokeswoman for the Georgia Department of Community Health, told Stateline that there were 5,548 people enrolled in the program as of Nov. 15 and that a total of 7,518 people were enrolled at one point — evidence, she said, that the program is helping people when transitioning from Medicaid to private insurance.
Even entitled people can’t keep up.
– Leah Chan, director of health equity at the Georgia Budget and Policy Institute
But in its first year, Pathways to Coverage only took enrollments about 4,200 people – much less than that The state had predicted 25,000. The Cost of the program According to KFF, a nonprofit health research group, spending reached $26.6 million at the end of 2023, and more than 90% of that went to administrative and consulting costs. If Georgia had opted for a full expansion under the ACA, the federal government would have covered 90% of the costs and the state would have covered about 359,000 people.
Leah Chan, director of health equity at the Georgia Budget and Policy Institute, said work requirements are particularly challenging for people living in rural areas.
“If you don’t have broadband internet at home, you won’t be able to upload the paperwork and your pay stubs,” Chan told Stateline. “Even those who are eligible cannot keep up, especially in rural areas where there are additional barriers to participation.”
“Learn from mistakes”
Benjamin Sommers, a professor of health economics at the Harvard TH Chan School of Public Health and one of the authors of the Arkansas study, said the experience with work requirements there and in Georgia should give other states pause.
“All that ended up happening was that because of bureaucracy, people lost coverage, became uninsured, and in some cases we saw that they had less access to health care,” Sommers said.
But Arkansas Republican state Rep. Aaron Pilkington, who serves on his chamber’s health committee, said the Medicaid operating rules are “100% on the table and something we will demand from the Trump administration.”
“They can find work through their employer and get better health insurance,” Pilkington said. He said volunteer and educational opportunities make the rules even more attractive.
Meanwhile, in some of the 10 states that have not expanded Medicaid under the ACA, including work requirements may be the only political way to get expansion over the finish line.
“Most Democrats I spoke with didn’t want the work requirements, but to get it through the Mississippi Legislature there will most likely be one,” Mississippi Republican state Rep. Sam Creekmore told Stateline.
“We looked at Georgia’s plan. We recognize the pitfalls and hopefully learn from mistakes.”
