House Republicans could make work requirements a condition of Medicaid eligibility, using it as a way to cut federal spending by removing low-income families and children from the federal health insurance program.
The preliminary budget proposals released earlier this month would require the Energy and Commerce Committee, which has jurisdiction over healthcare issues, to cut $880 billion from federal spending.
Related: Who could be impacted by Medicaid work requirements
As one means of reducing spending, lawmakers including House Speaker Mike Johnson (R-La.) and House Budget Committee Chair Jodey Arrington (R-Texas) have floated work requirements akin to the strategies states tried to implement during President Donald Trump's first term.
Johnson plans to put the budget proposals to a vote Tuesday. Lawmakers haven't published any details about what any work requirements could look like.
Here’s what to know about how a Medicaid work requirements proposal could affect healthcare.
What are work requirements?
If Republicans instituted work requirements, Medicaid applicants and enrollees would have to prove they’ve worked a certain number of hours in a given time period to receive benefits. Volunteer hours or time in school might be counted toward the tally.
During Trump's first term, states could apply to add work requirements to their Medicaid programs using Section 1115 waivers under the Social Security Act. The waivers provided states flexibility to experiment with how they administer federal assistance programs.
The Centers for Medicare and Medicaid Services approved 13 states’ waivers during Trump's first term, most of which have expired or were rescinded by CMS under former President Joe Biden, according to KFF, a nonprofit healthcare research organization.
One state, Georgia, has an active work requirements pilot underway. A federal judge in Georgia allowed the program to go forward in 2022.
How did Medicaid work requirements play out before?
In most states, they were embroiled in litigation and never got off the ground. Only two states implemented pilots, Arkansas and Georgia.
Arkansas’ program did not meaningfully increase employment, but did result in the state terminating about 18,000 people from its Medicaid rolls in the seven months it was active, according to a 2020 Health Affairs study.
Arkansas Governor Sarah Huckabee Sanders (R) announced in late January the state submitted a request to revive the pilot.
Georgia’s requirements are suppressing enrollment rates, said Leo Cuello, a research professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families. Only about 6,500 people are enrolled in Georgia’s “Pathways Program,” according to the Georgia Budget and Policy Institute, despite nearly 1.2 million uninsured people in 2023, according to the latest census data.
How would work requirements affect providers?
Providers face two key concerns.
Adding obstacles to Medicaid coverage would lead to a higher level of uninsured people, which would drive up uncompensated care costs for hospitals and community health centers.
Uncompensated care is already a significant federal expense. CMS estimated in August that it would distribute almost $6 billion in uncompensated care payments to hospitals between October 2024 and October 2025, which hospitals have said won't keep up with the cost of care.
Also, establishing a system for Medicaid enrollees to report their work hours would be extremely difficult for states, providers and participants, Cuello said. It would be prohibitively expensive for states to set up such a system, let alone hire enough staff to maintain it.
Numerous medical groups opposed work requirements during Trump’s first term, including the American Medical Association, the American Academy of Family Physicians, the American Academy of Pediatrics, the American Nurses Association, the American College of Physicians, the American Osteopathic Association and the American Psychiatric Association.
Why consider work requirements a second time?
Republicans in Congress are looking to make significant spending cuts as part of ongoing budget talks. House Republicans recently proposed $880 billion in cuts for the committee that oversees healthcare, at least some of which would need to come from Medicaid.
Cutting Medicaid is unpopular among voters, so it’s likely that some of the bigger ideas on the table — capping Medicaid spending or reducing the funding match rate states receive from the federal government — aren’t likely to move forward, Salo said.
Smaller proposals such as work requirements are much more likely to be enacted, Salo said.
Statutory work requirements would be a shift from Trump’s previous term. In the first version of these policies, states would voluntarily submit an application to CMS to modify their Medicaid programs. If a federal law is enacted, all states could be required to implement the coverage conditions.
