In 2018, the Trump Administration and GOP made several attempts to repeal the ACA and impose federal spending caps on the Medicaid program to reduce costs. These efforts were ultimately unsuccessful; however, a handful of states expanded their Medicaid programs and introduced work requirements during this time.

According to KFF, one out of five Americans receive health care through Medicaid. It has become the country’s largest source of health care coverage and accounts for 27% of total state expenditures. Due to program expansion and costs, House Republicans renewed their push for work requirements over the spring during debt ceiling negotiations with Democrats. They also proposed expanding the work requirements for individuals receiving food and cash assistance through SNAP and TANF. 

The Medicaid work requirement provision did not make it through negotiations; however, President Biden agreed to the expanded work requirements for food and cash assistance in exchange for a two-year suspension of the debt ceiling. Despite the outcome in Washington, some states are still pursuing work requirements for their Medicaid programs through Section 1115 waivers.

While Medicaid is a jointly funded program between the federal government and states, the states are responsible for administering it, and the Social Security Act allows them the flexibility to tailor their programs with Section 1115 waivers. These waivers require approval from the Secretary of Health and Human Services and can amend eligibility requirements or waive provisions of federal law under the condition that the projects promote the objectives of the Medicaid program.

States first used Section 1115 waivers to implement work requirements in 2017 under the Trump Administration. At the time, twelve states received approval from HHS. Shortly after, the Trump Administration was sued by health care advocates and civil rights groups, overturning the work requirement legislation in Arkansas and Kansas. As a result, some other states were also prohibited from implementing their provisions. 

Pathways to Coverage – GA’s Work Requirements

Shortly after President Biden transitioned into office, he reversed several other waivers that granted states approval to implement Medicaid work requirements. Georgia was one of the states affected by the decision and sued the administration. The District Court for the Southern District of Georgia ruled in favor of the state, citing that the administration did not consider whether reversing the waiver would result in less Medicaid coverage. Georgia has become the only state with a work requirement for Medicaid eligibility, and the state’s plan, Pathways to Coverage, launched at the beginning of this month. 

Work requirements have once again become a topic of debate among health care professionals and government officials. Some view the requirements as barriers to health coverage that go directly against the objectives of the Medicaid program. They argue that Medicaid is designed to provide insurance, not encourage employment. On the other hand, work requirement advocates say that the program has expanded far beyond its original objective, and states must rein in costs. Currently, states are navigating eligibility redeterminations, and they will have a significant impact on enrollment. Setting the work requirement debate aside, all states should be looking for ways to improve efficiency and cost avoid in their Medicaid plans.