Imposing work requirements for Medicaid eligibility is bad policy. Here’s why.

Imposing work requirements for Medicaid eligibility is bad policy.  Here’s why.

By: Deborah Gross and Eric Slade

Work requirements might sound to some like a worthy strategy for reducing dependency on federal health benefit programs and, with it, unnecessary government spending. But these policies actually will not have fiscal benefits. Indeed, these new requirements add new administrative hurdles for Medicaid recipients and may cause many to lose coverage despite meeting eligibility requirements.

As of June 2018, eleven states–Arkansas, Indiana, Kentucky, New Hampshire, Arizona, Kansas, Maine, Mississippi, Ohio, Utah, and Wisconsin—have applied for or received federal waivers from the Centers for Medicare and Medicaid Services allowing them to include work requirements as a condition for adults to receive Medicaid insurance benefits.

Proponents of work requirements for Medicaid have two main arguments, and, on their surface, both might seem compelling. The first is that requiring work saves the government money because it encourages “able bodied” adults to obtain jobs that offer private health insurance benefits and stop relying on government programs. The second is that working improves health, which leads to increased income and less dependency on government programs.

But most Medicaid beneficiaries are already working or exempt from these work requirements.

In 2016, 60% of adults in Medicaid who were not disabled and not elderly worked for pay either part-time (18%) or full-time (42%).  Exemptions from work requirements include age (older than 64 years or younger than 19 years), actively seeking work, being disabled, being a caregiver for a disabled family member, being enrolled in school, caring for young children, or being medically frail. In fact, a recent JAMA report estimated that only 2.8% of enrollees, or 2.1 million adults, could be considered not working and not eligible for an exemption.

According to a recent JAMA Internal Medicine report, dropping these nonworking individuals from Medicaid would save only 0.1% of Medicaid spending.   

That’s not much of a savings. In fact, it’s likely an over estimate of savings. It does not include the cost that states will pay to make sure enrollees comply with work requirements.  It does not include the additional costs to publicly supported health care systems in the form of uncompensated or charity care.  And because unemployed non-disabled adults on Medicaid tend to have less education and worse health, it fails to account for their greater dependence on future public disability and support programs that will likely be needed after losing Medicaid coverage.

Many who are working, elderly, or disabled will lose their insurance only because they may not be able to properly document their compliance with the new mandate.

Millions of Medicaid enrollees who under the prior rules are exempt from work requirements will be required to navigate a new and unfamiliar bureaucratic process to reapply for their eligibility too frequently. An unknown number may lose their eligibility for Medicaid because they cannot gather documents within the new timeframe, attend administrative reviews, or have the technical skill to submit documentation online. Sadly, dropping these individuals from Medicaid may be where much of the reduction in Medicaid expenditures will likely come from.

Advocates of work requirements in Medicaid justify their position by erroneously pointing to evidence from research showing that participation in paid work is associated with better health.  But chronic illness and functional impairments negatively influence one’s ability to work and maintain employment.  Moreover, many unemployed, able-bodied adults on Medicaid want work but have limited access to reliable transportation, a history of incarceration, unstable housing, or lack of affordable childcare, which keeps them from finding or maintaining a job.  This is the reality of being poor for many people in this country.

To save at most .1% in government Medicaid expenditures, we would drop the people who need it most; those with the least education and financial resources, parents of dependent children, and those in poor health.  This further erosion of the social safety net is not good fiscal policy and certainly does not make sense for improving public health. Stripping individuals of their Medicaid coverage means less access to necessary medical care and will further undermine individuals’ ability to remain independent of federal disability income supports.


Deborah Gross, DNSC, RN, FAAN is the Leonard and Helen Stulman Endowed Professor in Psychiatric and Mental Health Nursing professor at the Johns Hopkins School of Nursing. She is is best known for her work in promoting positive parent-child relationships and preventing behavior problems in preschool children from low-income neighborhoods.


Eric Slade, PhD, is an Associate Professor at the Johns Hopkins School of Nursing. He is an economist with expertise in public insurance programs.



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