Medicaid work requirement

What is a Medicaid work requirement?

A Medicaid work requirement is a provision that requires certain Medicaid enrollees to participate in “community engagement” activities (work, school, job training, volunteering, etc.) in order to maintain their health coverage.

Do Medicaid work requirements result in more people working?

No, Medicaid and SNAP work requirements do not result in more people working. This is due in large part to the fact that most people with Medicaid are either already working, would qualify for an exemption from a work requirement, or face various barriers to employment.¹

Medicaid work requirements result in fewer people with Medicaid, most of whom become uninsured after losing Medicaid. And they result in significant administrative expenses for a state’s Medicaid program.²

Do any states currently have Medicaid work requirements?

As of late 2024, Georgia is the only state in the country that has a Medicaid work requirement. It took effect in July 2023, for people who want to enroll in the state’s partial Medicaid expansion, which is called Georgia Pathways to Coverage. This program is available to adults under age 65 with household income below the poverty level, but only if they’re working at least 80 hours per month and reporting their work to the state.

But by mid-2024, a year after the program began, only 4,231 people had enrolled in Georgia Pathways.³ This extremely low enrollment is due in large part to the work requirement and associated paperwork.⁴

The Trump administration approved Georgia’s Medicaid work requirement in 2020, but the Biden administration subsequently revoked the approval. In 2022, however, a U.S. District Judge ruled that HHS acted in an “arbitrary and capricious” manner when they revoked Georgia’s Medicaid work requirement approval, thus clearing the way for Georgia to implement its Medicaid work requirement in conjunction with a partial expansion of Medicaid, starting in mid-2023.

What states are considering new Medicaid work requirements?

Several states are considering Medicaid work requirements or moving forward with the process of seeking approval for them:

• Ohio plans to submit a work requirement proposal to the federal government in early 2025, and is accepting public comments on the proposal until January 16, 2025.⁵ This stems from the budget legislation the state enacted in 2023.⁶ (As described below, Ohio previously received approval for a work requirement, but it was never implemented.)
• South Dakota voters approved a ballot measure in 2024 that allows the South Dakota legislature to impose a work requirement for the Medicaid expansion population. The state would also need federal approval to implement a work requirement (either via federal legislation that creates a blanket approval, or a state-specific 1115 waiver).⁷
• North Carolina expanded Medicaid eligibility in December 2023, under the terms of legislation enacted earlier that year. The bill directs the state to seek federal approval for a work requirement in the future “if there is any indication that work requirements as a condition of participation in the Medicaid program may be authorized” by CMS.⁸ Under the second Trump administration, North Carolina may pursue a work requirement for its Medicaid expansion enrollees.
• Mississippi, Kansas, and Idaho have considered legislation in recent years that called for Medicaid work requirements, but the bills have been unsuccessful. They may revisit these bills in 2025.⁹
  

Which states previously implemented Medicaid work requirements?

In addition to Georgia, five other states previously implemented Medicaid work requirements, although none of them are currently in effect. Arkansas, Indiana, Michigan, New Hampshire, and Utah implemented Medicaid work requirements between 2018 and 2020.

Arkansas was the only state in which people lost their coverage as a result of the work requirement. In the other four states where work requirements did become effective, they weren’t in effect long enough to result in coverage losses.

Utah and Michigan were the only states where Medicaid work requirements were in effect as of early 2020, and both had suspended their work requirements by the spring of 2020. In Michigan, this was due to a court ruling; in Utah, it was due to the COVID pandemic. And in 2021, the Biden administration officially withdrew federal approval for all of the previously-approved Medicaid work requirement waivers.

How do states get approval for Medicaid work requirements?

Medicaid work requirements need approval from HHS under an 1115 waiver. (Legislation introduced in Congress in September 2024 would allow states to implement Medicaid work requirements for adult enrollees who aren’t pregnant, disabled, or elderly, without the need to obtain specific federal permission.¹⁰ But until if and when this sort of legislation were to be enacted, a state has to obtain an approved 1115 waiver from CMS to implement a Medicaid work requirement.)

The concept of a work requirement had previously been a non-starter throughout the Medicaid program’s history, but the Trump administration encouraged states to submit waiver proposals for work requirements. Numerous states submitted waiver proposals. Ultimately, 13 states received approval from the Trump administration to implement Medicaid work requirements for at least some of their adult Medicaid enrollees (see chart below).