President Donald Trumpās return to the White House sent a clear signal about Medicaid to Republicans across the country: Requiring enrollees to prove they are working, volunteering, or going to school is back on the table.
The day after Trumpās inauguration, South Carolina GOP Gov. Henry McMaster asked federal officials to approve a . Ohio Republican Gov. Mike DeWine . Republicans in Congress are eyeing Medicaid work requirements as they seek to slash billions from the federal budget.
But, just as a second Trump administration reignites interest in work requirements, Georgia is proposing to scale back key parts of the nationās only active program. And Arkansas announced an effort to revive ā with fundamental changes ā a program that ended after a legal judgment in 2019.
The Georgia and Arkansas proposals, from the only two states to have implemented Medicaid work requirements, reveal the disconnect between rhetoric behind such programs and the realities of running them, said consumer advocates and health policy researchers.
āThey recognize that what they did the first time didn’t work,ā said Ben Sommers, a Harvard professor and a former health official in the Biden and Obama administrations. āIt should be a signal to federal policymakers: Don’t point to Georgia and Arkansas and say, āLet’s do that.āā
More than a dozen states had Medicaid during Trumpās first administration.
After an expensive and bumpy rollout, Georgia in January posted a draft renewal plan for its Georgia Pathways to Coverage program. The plan removes the requirement to document work every month and to pay premiums. Those key elements ā which supporters have argued promote employment and personal responsibility ā were never implemented, the state said.
Enrollees would still have to meet the work requirement when they first apply and when they renew each year. The draft plan also expands the group of people who can opt out of work reporting to include parents of children under age 6. A public comment period on the plan is open through Feb. 20.
“”°ł°ģ²¹²Ō²õ²¹²õā latest request to federal officials doesnāt require enrollees to report their work hours. Instead, it proposes checking whether people are working, caregiving, or fulfilling other qualifying activities by using data, which could include income, job history, educational status, whether a child lives at home, and other criteria, said Gavin Lesnick, a spokesperson for the stateās Medicaid agency.
People deemed ānot on track towards meeting their personal health and economic goalsā wonāt be disenrolled but can participate in a āsuccess coachingā program to maintain coverage, according to the stateās proposal. A public comment period on “”°ł°ģ²¹²Ō²õ²¹²õā program runs through March 3.
āFundamentally Flawedā
More than 90% of U.S. adults eligible for Medicaid expansion are already working or could be exempt from requirements, . Still, several states are quickly moving to restart Medicaid work requirements.
Besides the three states of Arkansas, Ohio, and South Carolina, Iowa and South Dakota are considering similar proposals. Lawmakers in Montana are weighing them as they debate renewing the stateās Medicaid expansion.
This week, House Republicans floated a budget proposal from the Energy and Commerce Committee, which oversees Medicaid, the state-federal health insurance program for people with low incomes or disabilities. Before the release of that plan, Speaker Mike Johnson said Republicans were discussing changes to Medicaid that include imposing work requirements.
Supporters of such requirements say Medicaid should be reserved for people who are working.
Right now, it ādisincentivizes many low-income families from earning additional incomeā because they would lose health coverage if they make too much money, said South Carolina Gov. McMaster in his January letter to federal officials. He has argued that a work-reporting requirement is āfiscally responsibleā and āwill incentivize employment.ā
There is showing such programs improve economic outcomes for people; the requirements donāt help people find jobs, but not having health insurance can keep them from working, health policy researchers say.
The goal of Ohioās plan is to focus āresources and efforts on those who are engaged with their health choices and independence,ā said the state. The plan doesnāt require most individuals to regularly āreport activities, fill out forms, or take any actionā beyond what is generally required for Medicaid enrollment. Ohio estimates that more than 61,000 people, or 8% of enrollees subject to its measure, would lose Medicaid eligibility in the first year.
Consumer advocates, health policy analysts, and researchers said the scaling back seen in recent work requirement proposals speaks to the challenges of mandating them for public benefits ā and could serve as a cautionary tale for Republicans in Washington, D.C., and across the country. The programs can eliminate people from the Medicaid rolls or suppress enrollment, while adding costly layers of bureaucracy, they said.
āAs a matter of health policy, work-reporting requirements in Medicaid are fundamentally flawed,ā said Leo Cuello, a researcher at the Georgetown Center for Children and Families.
Lessons Learned?
Arkansas got its initial program off the ground in 2018 before a federal judge said it was illegal. Unlike Georgia, the state had already expanded Medicaid. That work-reporting requirement led to more than 18,000 people losing coverage, in part because enrollees were unaware or confused about how to report they were working.
In his , Judge James Boasberg said its approval was āarbitrary and capriciousā because it failed to address a core goal of Medicaid: āthe provision of medical coverage to the needy.ā
“”°ł°ģ²¹²Ō²õ²¹²õā latest proposal tries to address a potential legal challenge by suspending, rather than terminating, health coverage through the end of the calendar year for people who donāt meet requirements.
āWe have worked to design this amendment taking into account lessons learned from previous work requirements,ā said Arkansas Medicaid Director Janet Mann at in late January announcing the new proposal.
But the requirements are “subjective,ā and the difference between suspension and termination isnāt meaningful, said Camille Richoux, health policy director of Arkansas Advocates for Children and Families.
āThe impact is the same: You can’t go to the doctor,ā she said. āYou can’t get your prescriptions filled.ā
In Georgia, the Pathways program, launched in 2023, has offered coverage to a small portion of those who would qualify for Medicaid if the state had fully expanded it to all low-income adults, as 40 others have done. With the proposed changes, the state estimates enrollment in Pathways would grow to as many as 30,000 people in the final year of the pilot. The state currently estimates at least 246,000 would become eligible for Medicaid under a full expansion.
About 6,500 people were enrolled in Pathways as of late January, said Grant Thomas, the stateās deputy Medicaid commissioner, . According to state officials, the program has cost more than $57 million in state and federal funds through December, with most of that money going toward program administration, not benefits.
āPathways is doing what it is designed to do: increase access to affordable health care coverage while lowering the uninsured rate across Georgia,ā said Russel Carlson, who oversees the stateās Medicaid program as commissioner of the Department of Community Health. The changes to Pathways are an attempt to āimprove the member experienceā while finding ways āto make government more efficient and accessible,ā he added.
Pathways requires that enrollees regularly submit documentation to prove they are working, but the program doesnāt include meaningful measures to help people find work, critics said. People who could be eligible for Pathways have said the whole process is time-consuming due to lengthy questionnaires, a glitchy system for uploading documents, and confusing technical language on the website, according to those working with potential enrollees.
āThere’s stuff that sounds good on paper, but when you go to implement it in real life, it’s costly and burdensome,ā said Leah Chan, director of health justice at the Georgia Budget and Policy Institute.
So far, Pathways has cost state and federal taxpayers nearly $9,000 per enrollee, largely back-end costs to run the program. States that have expanded Medicaid spent about $6,500 per enrollee in that group in 2021, according to .
Georgia GOP Gov. Brian Kemp has said heās committed to his signature health program, but some Republican state lawmakers to consider full expansion.
A group of Democratic senators cited Ńī¹óåś“«Ć½Ņīl Health News’ reporting last year when they asked the federal governmentās top watchdog to investigate Pathways spending.
Even with the proposed changes, some people, including those who work in the informal or gig economy, may not have official records and may be locked out of health coverage, said Laura Colbert, executive director of Georgians for a Healthy Future, a nonprofit consumer health advocacy organization. People caring for older children or aging relatives, older adults who struggle to find work, and those with medical conditions that prevent them from working still wouldnāt qualify for health coverage, she said.
āThe Pathways program just doesnāt reflect the reality of how people are working,ā Colbert said. āPathways is a program that has clearly been developed by people who have had salaried jobs with predictable incomes.ā
