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Proposals to Couple Medicaid Expansion With Work Requirements: Frequently Asked Questions

States that have expanded Medicaid to low-income adults under the Affordable Care Act have seen large gains in coverage; improvements in access to care, financial security, and health; reductions in uncompensated care costs; and, in many cases, state budget savings. Now, some non-expansion states are considering coupling Medicaid expansion with policies that take coverage away from people not meeting work requirements. Most of these policies require enrollees to report 80 hours of work or work-related activities each month in order to keep their coverage.

Will a Medicaid Expansion With Work Requirements Close the Coverage Gap?

No. Taking coverage away from people not meeting work requirements means that many of the people who would have been covered by Medicaid expansion won’t get coverage. In Arkansas, the only state that has implemented a Medicaid work requirement so far, almost 1 in 4 people subject to the requirement (23 percent, or more than 18,000 people) have lost coverage.

Why Do People Lose Coverage Under These Policies?

Most of those losing coverage under Medicaid work requirements are likely working or unable to work due to serious health needs or caregiving responsibilities. They lose coverage because they can’t overcome the bureaucratic hurdles required to claim an exemption from the policies, because they struggle with the systems for reporting their work hours, or because they work in unstable jobs where hours fluctuate from month to month. Other enrollees face severe barriers to work that may not qualify them for exemptions, such as lack of access to transportation.

How Will Work Requirements Affect Access to Care?

Medicaid expansion has substantially increased access to care, including preventive care, mental health and substance use treatment, and appropriate management of chronic conditions. Expansion has also improved enrollees’ financial security and health outcomes. For people losing coverage due to work requirements, these gains will be reversed.

People with disabilities and serious chronic conditions, including mental illness, and people with substance use disorders are at particular risk of losing coverage under work requirement policies, with especially harmful consequences. As the American Medical Association and other major physician, hospital, and patient groups wrote in a brief opposing Kentucky’s Medicaid work requirement, “Discontinuing coverage for patients who have already been diagnosed with… [a] chronic disease can be nothing short of catastrophic…. This care saves lives.”

In March 2019, a federal court blocked Arkansas’ and Kentucky’s waivers, including their work requirement policies, finding that the Department of Health and Human Services had not shown that the waivers advance Medicaid’s central goals. Although the court’s decision only directly affects these states, the decision may give states pause in adopting work requirement policies, since it’s likely they would find themselves locked in litigation.

What Can States Do to Help Medicaid Enrollees Find Work?

There is no evidence that Arkansas’ work requirement has helped anyone find a job. Instead, by making it harder for people to access the care they need to manage chronic conditions, it may have made it harder for them to work or to look for work.

States that are serious about helping Medicaid enrollees find work can instead invest in workforce promotion programs that connect people with services to reduce barriers to work. For example, a Montana program targets outreach and services to the minority of Medicaid enrollees who don’t have disabilities or similarly severe barriers to work but aren’t working. The program has shown promise, and it’s also cost effective. Montana allocated just $885,000 for the program’s outreach, trainings, and linkages to other services in fiscal year 2019, compared to the tens of millions of dollars per year that other states anticipate spending to administer complex work requirements.