Medicaid Work Requirements: Current Waiver and Legislative Activity
By Elizabeth Hinton, Jada Raphael and Amaya Diana / November 21, 2024
With Donald Trump returning to the presidency and Republican control of the Senate and House, work requirements are likely to be back on the agenda—through federal legislation or Medicaid waivers. Although past legislative attempts to incorporate work requirements into Medicaid statute failed, plans from Republican and conservative groups continue to support federal legislation to allow or require work requirements in Medicaid. A Congressional Budget Office analysis of a recent work requirement proposal shows that the policy would reduce federal spending due to reductions in enrollment and increase the number of people without health insurance but would not increase employment. Several states have also continued to pursue work requirement Section 1115 waivers, often tied to Medicaid expansion efforts. South Dakota just passed a ballot measure allowing the state to pursue a work requirement for its (newly implemented) Medicaid expansion population. The makeup of state legislatures and governor control are important, as Medicaid policy changes may require state legislative action or may be authorized at the direction of the governor. While a focus on work requirements remains, data show most Medicaid adults are working or face barriers to work. Among adults with Medicaid who are under age 65 and do not have Medicare or SSI, 91% are working, or are not working due to an illness, caregiving responsibilities, or school attendance.
This issue brief briefly highlights the history of Medicaid work requirements, describes recent state activity to advance work requirement policies, and recaps the landscape of work requirement approvals and pending requests at the end of President Trump’s first term.
Work Requirement Waiver History
For the first time in the history of the Medicaid program, the Trump administration encouraged and approved Section 1115 waivers that conditioned Medicaid coverage on meeting work and reporting requirements, approving 13 state work requirement waivers. Only Arkansas implemented such requirements with consequences for noncompliance, which resulted in over 18,000 people losing coverage before a federal court deemed the work requirement unlawful. While the vast majority of enrollees were working or qualified for exemptions, barriers with meeting reporting requirements led to people getting dropped from the program. Other states that began implementation did not disenroll those who did not comply and instead paused implementation due to litigation and/or the COVID-19 pandemic.
The Biden administration withdrew Medicaid work requirement waivers in all states that had approvals, concluding that these provisions do not promote the objectives of the Medicaid program, such as promoting coverage for low-income people. Although CMS withdrew work and premium requirements in Georgia’s waiver, these provisions remain in place after a federal judge overturned the CMS withdrawal. While work requirements waivers were the subject of litigation during the Trump and Biden administrations, the Supreme Court never ruled on the issue leaving it open for future administrations; however, any future waivers with work requirements would likely face legal challenges.
Work Requirement Waiver Activity
Work Requirements Currently Implemented
Georgia’s “Pathways” waiver expands eligibility to 100% of the federal poverty level (FPL) ($25,820 for a family of three, $15,060 for an individual in 2024) for parents and childless adults, with initial and continued enrollment conditioned on meeting work requirements. This is not a full Medicaid expansion under the ACA and does not qualify for enhanced federal matching funds. The waiver was implemented in July 2023. Over a year into the demonstration, enrollment remains low—as of October 2024, the state had only enrolled about 5,100 adults, a fraction of the estimated 175,000 adults in the Medicaid “coverage gap” in Georgia (individuals who did not qualify previously for Medicaid with incomes below poverty, making them ineligible for premium subsidies in the ACA Marketplace). As of the end of CY 2023, over 90% of the $26.6 million spent on the Pathways program was spent on administrative and consulting costs (largely through contracts with Deloitte consulting), as opposed to spending on health care costs. The demonstration is set to expire on September 30, 2025.
Recent State Legislative Consideration of Work Requirements Tied to Medicaid Expansion
A few states have introduced or passed legislation tying the implementation or adoption of the ACA Medicaid expansion to work requirements (also see Appendix table for additional state-by-state details).
South Dakota adopted the Medicaid expansion through a ballot initiative in 2022; coverage began on July 1, 2023. In early 2024, the state legislature passed a resolution adding a 2024 ballot measure that asked voters for approval to allow the state to impose work requirements on certain adults eligible for Medicaid expansion coverage. The measure passed (with 56% of voters in favor). The state must still seek CMS approval to implement work requirements.
The March 2023 legislation that adopted the ACA Medicaid expansion in North Carolina includes a provision to seek approval for work requirements if there is any indication that CMS would approve such a waiver. Medicaid expansion coverage in North Carolina began on December 1, 2023. In less than a year, nearly 580,000 expansion adults have enrolled.
After a failed effort in 2024, the Mississippi legislature may revisit whether to adopt and implement the ACA Medicaid expansion with a work requirement during the 2025 legislative session (which starts in January).
In January 2024, bills to introduce the Kansas governor’s proposal to expand Medicaid, which for the first time included a work requirement, were referred to the legislature. While the legislature held a hearing on the governor’s proposed legislation, both the House and Senate bills died in committee.
In January 2024, legislators in Idaho introduced a bill that would have repealed the state’s Medicaid expansion if work requirements and other conditions were not met, but it failed to advance after a House committee voted to hold the bill.
Work Requirement Requests Submitted During Biden Administration
In June 2023, Arkansas requested federal approval to condition Medicaid expansion QHP coverage (expansion adults in Arkansas are enrolled in ACA Marketplace plans) on meeting a work requirement. Individuals that do not comply with workforce activity requirements, including following individualized plans created by assigned “care coordinators,” would be transitioned from Marketplace coverage to fee-for service coverage (where individuals may face different provider networks). This waiver remains pending at CMS.
Recap: Work Requirement Approvals & Pending Requests at End of President Trump’s First Term
CMS under the Trump administration approved waivers with work requirements in 13 states. Across states, work requirement waivers were generally similar in conditioning Medicaid coverage for certain adults on reported employment or other qualifying activities, with some variation in technical details. For example, waivers varied by population (with most applying to expansion adults), exemptions (e.g., for older age or medical frailty), qualifying activities, number of required hours, reporting methods/requirements, and consequences for noncompliance. Nine additional state work requirement requests were pending (i.e., had not been approved) at the end of President Trump’s first term. For state-level detail on the approved waivers as well as additional requests that were not approved by the end of the Trump administration, see KFF’s 1115 waiver tracker.
Note that work requirement waivers submitted to the Trump administration date back several years. Changes in the makeup of state legislatures and governors will impact state interest in pursuing these policies. Some states require state legislative action before state plan amendments or Section 1115 waiver requests can be submitted by the state Medicaid agency to CMS for federal approval and others do not.
