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Medicaid work requirements during the Biden administration

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Work requirements for public assistance
Work requirements
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What are Medicaid work requirements?
Medicaid work requirements are policies that condition eligibility for Medicaid benefits on participation in work or related activities for certain adult enrollees. These activities may include employment, job training, education, or community service. In 2025, Congress passed the One Big Beautiful Bill Act (OBBBA), which created the first federally mandated Medicaid work requirements. The law requires states to implement a monthly 80-hour community engagement requirement for adults in the Affordable Care Act’s Medicaid expansion group by January 1, 2027, though states are able to apply for a good faith delay through December 31, 2028. As of February 2026, Georgia was the only state with an active state-level Medicaid work requirement.[1]

Why does it matter?
Medicaid provides health coverage to more than 70 million low-income individuals and families. The enactment of a federal work requirement represents a shift in how eligibility is determined — replacing a state-by-state waiver process with a national mandate. This shift reflects different approaches to the balance between state autonomy and federal oversight of public assistance, as well as the question of how much flexibility states should have in administering federally funded benefit programs. The policy has been a point of difference between presidential administrations, with the first Trump administration encouraging state adoption and the Biden administration reversing course before Congress established a nationwide standard in 2025.

What is the background?
Before the enactment of the OBBBA in 2025, there were no federally mandated work requirements for Medicaid. States could implement such policies by applying for a Section 1115 waiver from the Centers for Medicare and Medicaid Services (CMS).[2] During the first Trump administration, 13 states received approval to implement work requirements, but most efforts were blocked by legal challenges. Courts in several states ruled that CMS had not adequately considered the risk of coverage loss, and the Biden administration later withdrew all 13 waivers. Georgia was the only state to successfully defend its waiver in court, and it implemented work requirements in 2023.[3]

What are states doing?
Under the OBBBA, all states must implement work requirements by January 1, 2027, but are able to apply for early implementation or request a delay through December 31, 2028. As of December 2025, seven states, Arizona, Arkansas, Iowa, Ohio, South Carolina, Utah, and Montana, had submitted waiver requests to CMS to implement Medicaid work requirements and Georgia remained the only state with an active Medicaid work requirement.[4]

What are the arguments?
Proponents of Medicaid work requirements argue that they improve recipient health, ensure benefits are reserved for the truly needy, and help reduce poverty by encouraging employment.

Opponents of Medicaid work requirements argue that they worsen health and employment outcomes, cause people to lose coverage due to administrative burdens, and make it harder for those truly in need to access care.

This page features information on Medicaid work requirements during the Biden administration.

HIGHLIGHTS
  • CMS approved Medicaid work requirement waivers in 13 states during the Trump administration. Of these waivers, only Arkansas fully implemented its program before the Biden administration directed the agency to withdraw all approved waivers.[5]
  • Georgia implemented Medicaid work requirements on July 1, 2023, through the Georgia Pathways program. Click here to learn more.

    • Background of Medicaid work requirements

    See also: Centers for Medicare and Medicaid Services

    Medicaid, established by the Social Security Act of 1965, is a nationwide program that provides health coverage for qualifying individuals. The program is jointly funded by the federal government and the states. The states manage Medicaid eligibility, benefits, and administration within federal guidelines.

    Medicaid work requirements are mandated work-related activities that Medicaid recipients must complete to qualify for benefits, such as working, pursuing education, participating in a work program, or volunteer activities. As of the first quarter of 2026, Georgia was the only state with active Medicaid work requirements. The One Big Beautiful Bill Act (OBBBA), which was signed into law on July 4, 2025, required states to implement a work requirement of at least 80 hours per month for able-bodied adults in the Affordable Care Act expansion group by January 1, 2027.[1]

    Section 1115 waivers

    Before the enactment of the OBBBA, waivers under Section 1115 of the Social Security Act were sometimes used to gain approval for state-level Medicaid work requirement policies, such as Georgia's policy, which was implemented in 2023. Work requirements are not the only policies that can be approved under Section 1115.

    This section of statute gives the secretary of Health and Human Services (HHS) authority to approve any "experimental, pilot, or demonstration project which, in the judgment of the Secretary, is likely to assist in promoting the objectives of public assistance programs in a State or States." The Centers for Medicare and Medicaid Services (CMS) performs a case-by-case review of Section 1115 applications to determine whether the stated goals are aligned with Medicaid objectives. State applications for Section 1115 waivers must be budget neutral to the federal government, meaning that a state’s experimental project cannot increase federal Medicaid expenditures. Section 1115 waivers give states flexibility to design and improve programs by implementing state-specific policies to serve Medicaid recipients at the state level.[6]

    CMS approved Medicaid work requirement waivers under Section 1115 in 13 of the 22 states that applied during the first Trump administration. Of these waivers, only Arkansas fully implemented its program before the Biden administration directed the agency to withdraw all approved waivers.[7] Georgia implemented Medicaid work requirements on July 1, 2023, through the Georgia Pathways program. Click here to learn more.

    The OBBBA allowed states to apply for Section 1115 waivers to implement work requirements for Medicaid ahead of the January 2027 deadline, but did not allow states to use these waivers to waive the work requirements.[1] See the map below to see states that have applied for Section 1115 waivers for Medicaid work requirements since January 2025. Some of these waiver requests were submitted before the enactment of the OBBBA and others were submitted afterwards. All of these waivers would enact some form of Medicaid work requirements ahead of the OBBBA's January 1, 2027 deadline if approved, but not all meet the new federal standards.[8]

    Only one state, Georgia, had active Medicaid work requirements as of January 2026. The state's work requirements were implemented under a Section 1115 waiver in July of 2023 and were originally set to expire in September of 2025. Georgia received a waiver extension through December 31, 2026.[8]

    As of January 2026, one state had announced its intention to implement Medicaid work requirements ahead of schedule without the use of a Section 1115 waiver. Nebraska's governor, Jim Pillen, announced that the state will begin enforcing work requirements for Medicaid recipients on May 1, 2026. Nebraska was using a state plan amendment instead of a Section 1115 waiver. States seeking to amend their state Medicaid plans still must seek approval from CMS.[8][9]

    Medicaid work requirements during the Biden administration

    See also: Medicaid work requirements during the Trump administration

    This section provides information on activities affecting Medicaid work requirements during the Biden administration.

    CMS withdrawal of Medicaid work requirements during the Biden administration

    CMS withdrew 13 approved waivers for Medicaid work requirements during the Biden administration.

    President Joe Biden (D) on January 28, 2021, issued Executive Order 14009 and directed HHS to review waivers that risk significant coverage losses.[10]

    CMS in February 2021, began issuing final withdrawals for all states that had work requirement approvals under Section 1115 waivers. Though Arkansas filed suit arguing that its work requirements were lawful, the U.S. Supreme Court on March 11, 2023, removed the case from its docket and did not provide reasoning with its cancellation notification.[10][11]

    Georgia Medicaid expansion and work requirements

    Georgia lawmakers in 2019 passed Senate Bill 106, which created a state-developed protocol—known as Georgia Pathways—to return to historical Medicaid eligibility standards and implement a partial Medicaid expansion to cover adults with households below the poverty level who work at least 80 hours per month.[12]

    Georgia submitted its Georgia Pathways plan to CMS in December 2019 and was approved for a Section 1115 waiver in October 2020, effective July 1, 2021. CMS notified Georgia that the work requirement for Medicaid eligibility was being reconsidered in February 2021. Georgia officials replied in March 2021, arguing that work requirements were part of their plan to expand Medicaid coverage, and suspended Medicaid expansion until work requirements were approved.[12]

    Georgia filed a lawsuit against CMS and HHS in January 2022 and asked the United States District Court for the Southern District of Georgia to allow the state to proceed with Georgia Pathways as it was initially approved. The U.S. District Court for the Southern District of Georgia ruled in favor of the state on August 19, 2022, and allowed the state to move forward with Georgia Pathways.[12][13]

    Georgia became the only state to have a Medicaid work requirement in place when Georgia Pathways took effect on July 1, 2023. The Georgia Department of Community Health (DCH) announced the launch of the Georgia Pathways to Coverage program on July 5, 2023. The program defines employment and training as qualifying work activities.[14][15]


    See also

    External links

    Footnotes

    1. ↑ 1.0 1.1 1.2 Congress.gov, "H.R.1 - 119th congress (2025 - 2026)," July 4, 2025 Cite error: Invalid <ref> tag; name "obbba" defined multiple times with different content
    2. ↑ Social Security, Demonstration Projects, accessed May 15, 2023
    3. ↑ Kaiser Family Foundation, An Overview of Medicaid Work Requirements, accessed May 8, 2023
    4. ↑ KFF, "Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State," updated August 12, 2025
    5. ↑ Kaiser Family Foundation, An Overview of Medicaid Work Requirements, accessed May 8, 2023
    6. ↑ Medicaid, Section 1115 Demonstrations, May 5, 2023
    7. ↑ Kaiser Family Foundation, An Overview of Medicaid Work Requirements, accessed May 8, 2023
    8. ↑ 8.0 8.1 8.2 KFF.org, "Tracking Implementation of the 2025 Reconciliation Law Medicaid Work Requirements"
    9. ↑ Nebraska DHHS, "Work Requirements"
    10. ↑ 10.0 10.1 Kaiser Family Foundation, Overview of Medicaid Work Requirements, accessed May 5, 2023
    11. ↑ JD Supra, Supreme Court Cancels Arguments on Medicaid Work Requirements, accessed May 25, 2023
    12. ↑ 12.0 12.1 12.2 Health Insurance, Georgia Medicaid, accessed May 26, 2023
    13. ↑ Court Listener, Georgia v. Lasure, accessed May 26, 2023
    14. ↑ The Hill, Georgia Medicaid Work Requirements, accessed July 13, 2023
    15. ↑ Georgia DCH, Georgia Pathways Resources, accessed July 13, 2023
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