In their scramble to figure out how to reduce spending, Republicans are touting the idea of tying work requirements to Medicaid — a move that would impact 36 million Americans and, as some lawmakers acknowledged, could ultimately increase Medicaid program costs in their states.
The House’s budget resolution tasked the committee that oversees Medicaid and Medicare with cutting $880 billion, meaning Republicans will almost certainly have to find ways to curtail federal spending on those programs.
One of their most politically palatable options would be to require approximately 36 million able-bodied Medicaid adults to prove they work or file paperwork for exemptions. Speaker Mike Johnson recently argued that work requirements, along with other cuts, could get them to that figure without reducing people’s benefits, though the Congressional Budget Office projected in 2023 that Medicaid work requirements would only save approximately $109 billion over ten years.
“Work requirements, I’m 100% on board with. I don’t think you’ll get any argument from Republicans on that,” said Sen. Josh Hawley, who’s said multiple times he’d oppose cuts to Medicaid benefits. When asked if he worried about work-reporting programs increasing administrative costs for states’ social services agencies, he said he thought they “might help the state’s budget if it reduces folks on Medicaid who shouldn’t be.”
Hawley represents Missouri, a state considering legislation to mandate work requirements for Medicaid recipients. Critics of the legislation point out that the state’s social services agency already struggles to meet federal standards for processing paperwork and added red tape would slow that down even more — all while piling on more administrative costs.
When asked about the cost of states implementing work requirements, some Republican lawmakers pointed to the fact that states already administer work-reporting requirements for other social services, like the Supplemental Nutrition Assistance Program and Temporary Assistance for Needy Families.
But neither of those programs comes close to the size of Medicaid. Plus, of the people targeted by most work requirement proposals — that is, able-bodied adults who aren’t covered by Medicare or receiving Social Security income — 92% already work or would be exempt for other reasons, according to KFF, a health policy research organization.
The state of Kentucky reported to the Government Accountability Office in 2019 that implementing work requirements for Medicaid recipients would cost $271.6 million. The state’s Cabinet for Health and Family Services did not respond to NOTUS with an updated estimate, but the chair of the committee tasked with cutting $880 billion (the House Committee on Energy and Commerce) argued that work requirements would not actually cost his state that much.
“I have legislative friends in the legislature who know the budget, and they’ve never said that number,” Rep. Brett Guthrie of Kentucky, the committee chair, told NOTUS. “The American people think people should — if they’re going to get something free, and they have the ability to work, and not the issues that some people have in their lives, having to deal with elderly parents and so forth — then they should work.”
Guthrie said his committee will likely propose work requirements in some form but would consider administrative costs and work with state legislatures to figure out specific requirements: “It doesn’t have to be monthly. That’s what we need to see. Is it going to be too costly to be monthly? It could be quarterly. I mean, that’s where you have to figure out what the right way to do it is.”
Many lawmakers insisted work requirements would still reduce what they see as wasteful spending on beneficiaries that shouldn’t be getting taxpayer money.
“If you’re an able-bodied male, 26 years old, and you’re playing video games and not working, you should go to work. And there’s quite a few of those on Medicaid,” Rep. Andy Ogles told NOTUS. When asked if he had any specific examples of beneficiaries abusing health care benefits in mind, he said, “That’s a stupid question.”
And Rep. Dusty Johnson, who has proposed multiple bills to strengthen SNAP work requirements, said concerns about working people losing coverage because they fail to keep up with new administrative burdens — a much-documented effect of work requirement policies — is “fear-mongering.”
“There are already tens of millions of Americans who are subject to work requirements. This is not a new concept,” Johnson told NOTUS. “[Work requirements] are fantastically effective in helping people. … The evidence suggests that overwhelmingly, the impact, on average, is positive.”
He cited two states, Maine and Arkansas, as examples of work requirement policies that raised SNAP beneficiaries’ incomes. But Maine discontinued its efforts to mandate work for Medicaid beneficiaries in 2019 because they would “only impose burdensome mandates on people without increasing workforce participation.”
And with Medicaid work requirements, the data from Arkansas, the only state to ever enact a work-reporting requirement that disenrolled noncompliant beneficiaries, tells a much different story than the case Johnson made.
After it started requiring beneficiaries to report their hours in 2018, approximately 18,000 people lost their health care even though around 97% of them had exemptions or otherwise met the requirements. Studies found that beneficiaries were confused by the policy, and some lacked internet access to report their work hours.
While it did not increase beneficiaries’ workforce participation, it did increase medical debt, and delay care for more than half of those disenrolled: 64% of people affected delayed taking medication because they couldn’t afford it. The CBO concluded in 2023 that “the employment status of and hours worked by Medicaid recipients would be unchanged” by work requirements, but it would lead to more uninsured Americans. The CBO came to that conclusion in part thanks to data from Arkansas.
When asked about that report, Johnson suggested the CBO should not “draw conclusions on the basis of one state’s experience.”
It’s distant history for some lawmakers. Arkansas Sen. John Boozman told NOTUS he couldn’t even recall his state’s work requirement: “A lot’s happened since 2018.”
Some GOP-led states are already pursuing waivers from the Trump administration to implement their own work requirements. And some have already started their own experiments, with little success: Georgia, which never opted into the Affordable Care Act’s Medicaid expansion, launched Pathways to Coverage in July 2023, which allowed people under the federal poverty line to get coverage if they proved they worked or volunteered at least 80 hours a month or were enrolled in school.
As reported by ProPublica, the Pathways to Coverage program has cost federal and state taxpayers more than $86.9 million, and three-quarters of that went to consulting fees. That large price tag comes in spite of the program only having 6,500 participants and a backlog of 16,000 unprocessed applications.
“The program has been a failure from top to bottom. It’s been poorly administered, poorly designed, wastefully run,” Democratic Sen. Jon Ossoff told NOTUS. “The Pathways program hasn’t worked in Georgia, and we should be looking for opportunities to expand health coverage, not to slash it.”
But the potential cost is beside the point for some proponents. A couple of House Republicans told NOTUS they were less interested in the money states would spend implementing work requirements, and more interested in the principle of requiring beneficiaries to prove they work.
“If that’s what it takes to make sure that the right people are getting the benefits, then I’m all for it,” Rep. John Rutherford said, adding it’d be “the cost of doing business.”
Rep. Darrell Issa agreed: “America’s not better, regardless of the cost, if people who should be working aren’t working,” he said.
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Emily Kennard is a NOTUS reporter and an Allbritton Journalism Institute fellow.