President Donald Trump\u2019s return to the White House sent a clear signal about Medicaid to Republicans across the country: Requiring enrollees to prove they are working, volunteering, or going to school is back on the table.<\/p>\n
The day after Trump\u2019s inauguration, South Carolina GOP Gov. Henry McMaster asked federal officials to approve a work requirement plan<\/a>. Ohio Republican Gov. Mike DeWine plans to soon follow suit<\/a>. Republicans in Congress are eyeing Medicaid work requirements as they seek to slash billions from the federal budget.<\/p>\n But, just as a second Trump administration reignites interest in work requirements, Georgia is proposing to scale back key parts of the nation\u2019s only active program. And Arkansas announced an effort to revive \u2014 with fundamental changes \u2014 a program that ended after a legal judgment in 2019.<\/p>\n The Georgia and Arkansas proposals, from the only two states to have implemented Medicaid work requirements, reveal the disconnect between rhetoric behind such programs and the realities of running them, said consumer advocates and health policy researchers.<\/p>\n \u201cThey recognize that what they did the first time didn\u2019t work,\u201d said Ben Sommers, a Harvard professor and a former health official in the Biden and Obama administrations. \u201cIt should be a signal to federal policymakers: Don\u2019t point to Georgia and Arkansas and say, \u2018Let\u2019s do that.\u2019\u201d<\/p>\n More than a dozen states had Medicaid work requirement programs approved<\/a> during Trump\u2019s first administration.<\/p>\n After an expensive and bumpy rollout, Georgia in January posted a draft renewal plan<\/a> for its Georgia Pathways to Coverage program. The plan removes the requirement to document work every month and to pay premiums. Those key elements \u2014 which supporters have argued promote employment and personal responsibility \u2014 were never implemented, the state said.<\/p>\n Enrollees would still have to meet the work requirement when they first apply and when they renew each year. The draft plan also expands the group of people who can opt out of work reporting to include parents of children under age 6. A public comment period on the plan is open through Feb. 20.<\/p>\n Arkansas\u2019 latest request to federal officials<\/a> doesn\u2019t require enrollees to report their work hours. Instead, it proposes checking whether people are working, caregiving, or fulfilling other qualifying activities by using data, which could include income, job history, educational status, whether a child lives at home, and other criteria, said Gavin Lesnick, a spokesperson for the state\u2019s Medicaid agency.<\/p>\n People deemed \u201cnot on track towards meeting their personal health and economic goals\u201d won\u2019t be disenrolled but can participate in a \u201csuccess coaching\u201d program to maintain coverage, according to the state\u2019s proposal. A public comment period on Arkansas\u2019 program runs through March 3.<\/p>\n \u2018Fundamentally Flawed\u2019<\/strong><\/p>\n More than 90% of U.S. adults eligible for Medicaid expansion are already working or could be exempt from requirements, according to KFF<\/a>. Still, several states are quickly moving to restart Medicaid work requirements.<\/p>\n Besides the three states of Arkansas, Ohio, and South Carolina, Iowa and South Dakota are considering similar proposals. Lawmakers in Montana are weighing them as they debate renewing the state\u2019s Medicaid expansion.<\/p>\n This week, House Republicans floated a budget proposal to cut $880 billion<\/a> from the Energy and Commerce Committee, which oversees Medicaid, the state-federal health insurance program for people with low incomes or disabilities. Before the release of that plan, Speaker Mike Johnson said Republicans were discussing changes to Medicaid that include imposing work requirements.<\/p>\n Supporters of such requirements say Medicaid should be reserved for people who are working.<\/p>\n Right now, it \u201cdisincentivizes many low-income families from earning additional income\u201d because they would lose health coverage if they make too much money, said South Carolina Gov. McMaster in his January letter to federal officials. He has argued that a work-reporting requirement is \u201cfiscally responsible\u201d and \u201cwill incentivize employment.\u201d<\/p>\n There is no evidence<\/a> showing such programs improve economic outcomes for people; the requirements don\u2019t help people find jobs, but not having health insurance can keep them from working, health policy researchers say.<\/p>\n The goal of Ohio\u2019s plan is to focus \u201cresources and efforts on those who are engaged with their health choices and independence,\u201d said the state. The plan doesn\u2019t require most individuals to regularly \u201creport activities, fill out forms, or take any action\u201d beyond what is generally required for Medicaid enrollment. Ohio estimates that more than 61,000 people, or 8% of enrollees subject to its measure, would lose Medicaid eligibility in the first year.<\/p>\n Consumer advocates, health policy analysts, and researchers said the scaling back seen in recent work requirement proposals speaks to the challenges of mandating them for public benefits \u2014 and could serve as a cautionary tale for Republicans in Washington, D.C., and across the country. The programs can eliminate people from the Medicaid rolls or suppress enrollment, while adding costly layers of bureaucracy, they said.<\/p>\n \u201cAs a matter of health policy, work-reporting requirements in Medicaid are fundamentally flawed,\u201d said Leo Cuello, a researcher at the Georgetown Center for Children and Families.<\/p>\n Lessons Learned?<\/strong><\/p>\n Arkansas got its initial program off the ground in 2018 before a federal judge said it was illegal. Unlike Georgia, the state had already expanded Medicaid. That work-reporting requirement led to more than 18,000 people losing coverage, in part because enrollees were unaware<\/a> or confused about how to report they were working.<\/p>\n In his ruling that ended the program<\/a>, Judge James Boasberg said its approval was \u201carbitrary and capricious\u201d because it failed to address a core goal of Medicaid: \u201cthe provision of medical coverage to the needy.\u201d<\/p>\n Arkansas\u2019 latest proposal tries to address a potential legal challenge by suspending, rather than terminating, health coverage through the end of the calendar year for people who don\u2019t meet requirements.<\/p>\n \u201cWe have worked to design this amendment taking into account lessons learned from previous work requirements,\u201d said Arkansas Medicaid Director Janet Mann at a press conference<\/a> in late January announcing the new proposal.<\/p>\n But the requirements are \u201csubjective,\u201d and the difference between suspension and termination isn\u2019t meaningful, said Camille Richoux, health policy director of Arkansas Advocates for Children and Families.<\/p>\n \u201cThe impact is the same: You can\u2019t go to the doctor,\u201d she said. \u201cYou can\u2019t get your prescriptions filled.\u201d<\/p>\n In Georgia, the Pathways program, launched in 2023, has offered coverage to a small portion of those who would qualify for Medicaid if the state had fully expanded it to all low-income adults, as 40 others have done. With the proposed changes, the state estimates enrollment in Pathways would grow to as many as 30,000 people in the final year of the pilot. The state currently estimates at least 246,000 would become eligible for Medicaid under a full expansion.<\/p>\n About 6,500 people were enrolled in Pathways as of late January, said Grant Thomas, the state\u2019s deputy Medicaid commissioner, in a legislative hearing<\/a>. According to state officials, the program has cost more than $57 million in state and federal funds through December, with most of that money going toward program administration, not benefits.<\/p>\n \u201cPathways is doing what it is designed to do: increase access to affordable health care coverage while lowering the uninsured rate across Georgia,\u201d said Russel Carlson, the state\u2019s Medicaid director. The changes to Pathways are an attempt to \u201cimprove the member experience\u201d while finding ways \u201cto make government more efficient and accessible,\u201d he added.<\/p>\n Pathways requires that enrollees regularly submit documentation to prove they are working, but the program doesn\u2019t include meaningful measures to help people find work, critics said. People who could be eligible for Pathways have said the whole process is time-consuming<\/a> due to lengthy questionnaires, a glitchy system for uploading documents, and confusing technical language on the website, according to those working with potential enrollees.<\/p>\n \u201cThere\u2019s stuff that sounds good on paper, but when you go to implement it in real life, it\u2019s costly and burdensome,\u201d said Leah Chan, director of health justice at the Georgia Budget and Policy Institute.<\/p>\n So far, Pathways has cost state and federal taxpayers nearly $9,000 per enrollee, largely back-end costs to run the program. States that have expanded Medicaid spent about $6,500 per enrollee in that group in 2021, according to KFF researchers<\/a>.<\/p>\n Georgia GOP Gov. Brian Kemp has said he\u2019s committed to his signature health program, but some Republican state lawmakers have shown an openness<\/a> to consider full expansion.<\/p>\n A group of Democratic senators cited KFF Health News\u2019 reporting last year when they asked the federal government\u2019s top watchdog to investigate Pathways<\/a> spending.<\/p>\n Even with the proposed changes, some people, including those who work in the informal or gig economy, may not have official records and may be locked out of health coverage, said Laura Colbert, executive director of Georgians for a Healthy Future, a nonprofit consumer health advocacy organization. People caring for older children or aging relatives, older adults who struggle to find work, and those with medical conditions that prevent them from working still wouldn\u2019t qualify for health coverage, she said.<\/p>\n \u201cThe Pathways program just doesn\u2019t reflect the reality of how people are working,\u201d Colbert said. \u201cPathways is a program that has clearly been developed by people who have had salaried jobs with predictable incomes.\u201d<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\nUSE OUR CONTENT<\/h3>\n