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Reform proposals related to Medicaid work requirements
This page includes a selection of reform proposals related to Medicaid work requirements. These reform proposals come from state and federal legislative proposals, model legislative proposals, policy white papers, and scholarly articles.
For more information about the main areas of inquiry and disagreement related to work requirements for public assistance programs, click here.
Click on a link in the list below to learn more about each type of reform proposal:
- Require able-bodied adults receiving Medicaid benefits to work. This legislative proposal would require able-bodied adults to work, volunteer, or participate in a work program for a minimum number of hours to qualify for Medicaid.
- Allow reasonable accommodations and exceptions to Medicaid work requirements. This proposal would allow for reasonable accommodations or exemptions to Medicaid work requirements for individuals with certain health limitations.
- Require cost-benefit analyses as part of any proposal for new Medicaid work requirements. This proposal would require that any Medicaid work requirements should be grounded in data, specifically analyzing the costs and benefits of new policies.
- Expand administrative budgets, community outreach, and reporting efforts along with Medicaid work requirements. This reform proposal would accompany any new Medicaid work requirements with additional administrative and community support.
- See also: Medicaid work requirements
Medicaid is a nationwide program that provides health coverage for qualifying individuals and is jointly funded by the federal government and the states. The states manage Medicaid eligibility, benefits, and administration within federal guidelines. States can apply to Centers for Medicare and Medicaid Services for a Section 1115 waiver. The waiver allows the state to implement an experimental, pilot, or demonstration project, which includes the establishment of work requirements.
Medicaid work requirements are proposed mandated work-related activities that Medicaid recipients must complete to qualify for benefits, such as applying for a job, interviewing for a job, or participating in job training or volunteer activities. State-based work requirement policies for Medicaid were approved for 13 states during the Trump administration. All 13 states' Section 1115 waivers were revoked under the Biden administration.[1][2]
Georgia was the only state with Medicaid work requirements in place as of November 2024. Click here for more information on Georgia's Medicaid work requirements.
The following sections feature reform proposals related to Medicaid work requirements, such as instituting work requirements for able-bodied adults and providing certain accommodations and exceptions.
Require able-bodied adults receiving Medicaid benefits to work
This legislative proposal would require able-bodied adults to work, volunteer, or participate in a work program for a minimum number of hours to qualify for Medicaid.
Require able-bodied adults receiving Medicaid benefits to work at the federal level
- The 2025 budget reconciliation bill introduced what the bill called community engagement requirements for certain individuals, which states will be required to implement beginning January 1, 2027, as outlined in Section 71119 of the Act.[3] Applicable individuals must demonstrate at least 80 hours per month of community engagement, which can include:
- Work
- Community service
- Participation in a work program
- Half-time enrollment in an educational program
- A combination of the above activities
- Monthly income at least 80 times the federal hourly minimum wage.
- U.S. House Bill 1079, introduced on February 17, 2023, by Representative Matt Gaetz (R-Fla.), would require Medicaid recipients to work 120 hours per month. "Work requirements for able-bodied adults promote community engagement and a transition to self-sufficiency," argued Gaetz.[4][5]
- The Limit, Save, Grow Act of 2023, which passed the U.S. House in April 2023 but did not become law, proposed that "the community engagement requirement is for individuals ages 19 through 55 to work, engage in community service, or participate in a work program (or a combination of these) for at least 80 hours per month. The section prohibits federal payments for, and allows state Medicaid programs to disenroll, individuals who do not meet these requirements for three or more months in a year."[6]
Require able-bodied adults receiving Medicaid benefits to work at the state level
- Georgia became the only state to have a Medicaid work requirement in place when Georgia Pathways took effect on July 1, 2023. The new work eligibility requirement states that "In order to be eligible for coverage under Georgia Pathways, an individual must meet an hours and activities threshold of 80 hours per month of engagement in a qualifying activity (or combination of activities ) such as employment, community services, or education and have an income up to 100% of the FPL."[7]
- A ballot measure was passed in South Dakota during the November 2024 election that proposed amending the South Dakota constitution to provide that the state may impose work requirements for Medicaid. The amendment did not impose any requirements; it allowed the state to consider applying for a Section 1115 waiver and impose work requirements for Medicaid going forward.
Allow reasonable accommodations and exceptions to Medicaid work requirements
This proposal would allow for reasonable accommodations or exemptions to Medicaid work requirements for individuals with certain health limitations.
- Health policy professors Hefei Wen, Brendan Saloner, and Janet Cummings stated in a 2019 Health Affairs article that “people who may be subject to the requirements have an elevated prevalence of behavioral and other chronic health conditions. If work requirements are to be a continued piece of Medicaid policy, policy changes must also be adopted to ensure that Medicaid covers a full continuum of evidence-based behavioral health services and that Medicaid enrollees with work-limiting conditions are given reasonable accommodations and exemptions.”[8]
- Academics Richard G. Frank and Sherry A. Glied in a 2018 article argued for certain mental health medical exemptions, stating that “[s]tates with waivers seeking to implement a medical frailty exemption will need to establish a definition of frailty that considers mental and substance use disorders."[9]
Require cost-benefit analyses as part of any proposal for new Medicaid work requirements
This proposal would require that any Medicaid work requirements should be grounded in data, specifically analyzing the costs and benefits of new policies.
- Professor and pediatrician Aaron E. Carroll wrote in a 2018 article that “any change in policy be grounded in evidence and thoughtful in implementation… At this time, it’s not clear whether creating new work requirements would yield large savings, given how few beneficiaries qualify as 'able bodied' and unemployed. It’s not clear how many deserving beneficiaries might lose coverage and suffer losses because of complexities in the program. It’s not clear how much it would cost to implement such a program and whether that cost might exceed the savings. It’s not even clear whether this program would achieve even the most basic rationale of incentivizing more able-bodied beneficiaries to work. Given that, it’s not clear why so many states are eager to rush to implement work requirements for Medicaid recipients without having answers for these questions.”[10]
Expand administrative budgets, community outreach, and reporting efforts along with Medicaid work requirements
This reform proposal would accompany any new Medicaid work requirements with additional administrative and community support.
- The Urban Institute's 2019 research report, "Lessons from Launching Medicaid Work Requirements in Arkansas," stated, “Though the federal courts have yet to determine the fundamental legality of Medicaid work requirements, key informants and focus group participants identified several lessons learned and potential strategies to address the challenges surrounding Arkansas’s Medicaid work requirements— strategies that could reduce coverage losses and promote individuals’ ability to work—including expanding the scope, depth, and intensity of community-based outreach and education efforts; expanding and simplifying the means and methods available for reporting work and community engagement activities; and increasing funding for work support agencies and infrastructure so they have the expanded capacity to help Medicaid enrollees gain employment. However, many stakeholders we spoke with believed that beneficiaries would face barriers to compliance even if these strategies were implemented. The Arkansas experience provides a cautionary tale for other states considering adoption and implementation of Medicaid work requirements.”[11]
Expand eligible work activities for Medicaid
This reform proposal would broaden the types of activities that satisfy Medicaid work requirements in order to expand program access.
- The 2025 House budget reconciliation bill, which was signed into law on July 4 2025, proposed federal Medicaid work requirements. The reconciliation bill provisions institute a work requirement similar to Georgia's, which requires recipients to work or complete other approved activities for 80 hours a month to remain eligible for benefits. Unlike Georgia, the budget reconciliation bill also allows individuals to maintain eligibility if they can prove they receive a monthly income of 80 times the federal hourly minimum wage.[12]
- Click here for a more comprehensive overview of work requirements policies in the 2025 House budget reconciliation bill.
See also
- Arguments about work requirements for public assistance programs
- Medicaid work requirements
- Medicaid work requirements during the Biden administration
- Medicaid work requirements during the Trump administration
- Medicaid work requirements in the states
External links
Footnotes
- ↑ Kaiser Family Foundation, Overview of Medicaid Work Requirements, accessed May 5, 2023
- ↑ JD Supra, Supreme Court Cancels Arguments on Medicaid Work Requirements, accessed May 25, 2023
- ↑ Congress.gov, "H.R.1 - One Big Beautiful Bill Act ", July 1, 2025
- ↑ "Congress.gov," "Medicaid Work Requirements Act," accessed December 19, 2023
- ↑ "Matt Gaetz," "Matt Gaetz Leads 5 Lawmakers in Calling for President Biden to Enact Work Requirements to Cut Spending as Debt Crisis Looms," accessed December 21, 2023
- ↑ "Congress.gov," "accessed December 19, 2023
- ↑ "Medicaid.gov," "Georgia Section 1115 Demonstration waiver application," accessed January 19, 2024
- ↑ "Health Affairs," "Behavioral And Other ChronicConditions Among Adult Medicaid Enrollees: Implications For WorkRequirements," accessed December 12, 2023
- ↑ "Psychiatric Services," "Psychiatric Services," accessed December 12, 2023
- ↑ "JAMA," "The Problem With Work Requirements for Medicaid," accessed December 12, 2023
- ↑ "Urgan Institute," "Lessons from Launching Medicaid Work Requirements in Arkansas," accessed December 12, 2023
- ↑ Congress.gov, "H.R.1 - One Big Beautiful Bill Act," May 22, 2025
