Workers sort peaches at a packing house after they were harvested from the trees of a Georgia farm in July 2023. Georgia has work requirements under its partial expansion of Medicaid, but its program has fallen far short of enrollment projections and has cost more than $26 million. (Joe Raedle/Getty Images)

Trevor Hawkins, an attorney at Legal Aid of Arkansas, remembers how busy his job got when the state for a time imposed work requirements on Medicaid recipients: His office was swamped with frantic phone calls from people who said they couldn’t comply with the new rule because they weren’t healthy enough to work or had to care for sick relatives.

“A whole heap of folks, after a month or two, started getting notices saying, ‘Hey, you’re out of compliance, and you’re going to lose your coverage,’” Hawkins told Stateline. For many people, he said, keeping their coverage was “absolutely vital to maintaining their health or getting better so they might work again.”

In June 2018, Arkansas became the first state to require some Medicaid recipients to work, volunteer, go to school or participate in job training to receive benefits. By the time a federal judge halted the policy in April 2019, 18,000 adults had lost coverage.

Arkansas was one of 13 states that received permission to impose work rules on at least some Medicaid recipients during the last Trump administration. Nine additional states requested permission to enact Medicaid work requirements during Trump’s term but had not won approval by the time it ended.

When the Biden administration came into office, it rescinded all the approvals. But now that Trump is coming back, many of those states will try again — and they’ll have a supportive U.S. Congress in their corner.

Republicans on Capitol Hill are eager to find ways to pay for extending tax cuts enacted during Trump’s first term in office, and Medicaid — funded jointly by the federal government and the states — is in their sights. Requiring states to establish Medicaid work rules, as many Republicans would like to do, would cut federal spending by an estimated $109 billion over a decade, according to the Congressional Budget Office. That’s because the cost for about 900,000 people would shift entirely to states, while another 600,000 people would become uninsured, CBO estimated. About 72.4 million people are enrolled in Medicaid.

Arkansas renewed its efforts even before Trump’s victory. Last year, Republican Gov. Sarah Huckabee Sanders requested federal approval from the Biden administration to apply work rules to able-bodied adults who are covered through the state’s expansion of Medicaid under the Affordable Care Act, and who are enrolled in health plans that Arkansas Medicaid purchases for them on the state’s health insurance exchange. That application is pending.

Georgia, after prevailing in a legal fight with the Biden administration, already has work requirements in place for people covered by its partial expansion of Medicaid. And Idaho, Mississippi, Oklahoma, South Dakota and Tennessee have pending requests to require at least some of their Medicaid recipients to work.

Meeting requirements

Supporters say requiring Medicaid recipients to work, study or train for a career gives them a boost toward self-sufficiency and financial stability. Kristi Putnam, the secretary of the Arkansas Department of Human Services, said in a statement announcing her state’s latest request that it would challenge people to “embrace economic opportunities that can lead to true job advancement.”

“Meaningful work connects people to purpose — and through the pandemic we have seen negative mental health impacts from people feeling disconnected,” Putnam said.

Critics, however, say such rules end up hurting far more people than they help. In a 2020 study examining how the Arkansas work requirements played out, researchers from the Harvard T.H. Chan School of Public Health “found no evidence that the policy succeeded in its stated goal of promoting work and instead found substantial evidence of harm to health care coverage and access.”

More than 95% of the Arkansas beneficiaries the researchers surveyed already met the work requirement or should have qualified for an exemption. The main reason people lost coverage, the researchers found, was because they had trouble verifying that they were complying with the rules. Many of those who lost their coverage stopped taking their medications, delayed care and fell into medical debt.

“Our results should provide a strong note of caution for federal and state policy makers considering work requirement policies in the future,” the researchers concluded.

Under the rules Arkansas put in place during the first Trump administration, Medicaid participants under age 50 had to report that they spent at least 80 hours each month working, attending school, in job training or volunteering. The rule only applied to people who became eligible after Arkansas expanded Medicaid under the ACA to cover adults making up to 138% of the federal poverty level. And people were exempt if they were pregnant, had a child under 18 at home, were disabled, had to care for a person unable to care for him or herself, were in alcohol or drug treatment, or were in school or job training full time.

About 70,000 of the roughly 270,000 Arkansans on Medicaid were subject to the new rules, and about 1 in 4 of those lost coverage.

Unlike Arkansas, Georgia has not expanded Medicaid under the Affordable Care Act. But its Pathways to Coverage program, launched in July 2023, allows people with household incomes up to 100% of the federal poverty level who aren’t already eligible for Medicaid to enroll in the program if they fulfill work requirements. Georgia’s qualifying activities and exemptions are similar to the ones Arkansas had.

Fiona Roberts, a spokesperson for the Georgia Department of Community Health, told Stateline that as of Nov. 15, there were 5,548 people enrolled in the program and that a total of 7,518 people had been enrolled at some point — evidence, she said, that the program is helping people move from Medicaid to private insurance.

But in its first year, Pathways to Coverage only enrolled about 4,200 people — many fewer than the 25,000 the state had predicted. The cost of the program as of the end of 2023 was $26.6 million, and more than 90% of that went toward administrative and consulting costs, according to KFF, a nonprofit health research group. If Georgia had opted for a full expansion under the ACA, the federal government would have picked up 90% of the tab and the state would have covered about 359,000 people.

Leah Chan, director of health justice at the Georgia Budget and Policy Institute, said work requirements are particularly challenging for people living in rural areas.

“If you don’t have broadband internet at your house, you’re not going to be able to upload the documentation and your pay stubs,” Chan told Stateline. “Even eligible people can’t keep up with it, particularly in rural areas where there are additional barriers to participation.”

‘Learning from mistakes’

Benjamin Sommers, a professor of health care economics at the Harvard T.H. Chan School of Public Health and one of the authors of the Arkansas study, said the experience with work requirements there and in Georgia should give other states pause.

“All that ended up happening was people lost coverage due to red tape, became uninsured, and in some cases, we saw that they had worse access to health care,” Sommers said.

But Arkansas Republican state Rep. Aaron Pilkington, who serves on the health committee in his chamber, said Medicaid work rules are “100% on the table and something we’ll look to ask for from the Trump administration.”

“They can find work and get better health insurance through their employer,” said Pilkington. He said the volunteering and education options make the rules even more attractive.

Meanwhile, in some of the 10 states that have not expanded Medicaid under the ACA, the inclusion of work requirements might be the only way politically to get expansion over the finish line.

“Most of the Democrats I’ve spoken to did not want the work requirements, but to get it passed through the Mississippi legislature it’s most likely going to have one,” Mississippi Republican state Rep. Sam Creekmore told Stateline.

“We’ve looked at Georgia’s plan. We recognize the pitfalls and are hopefully learning from mistakes.”

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Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: info@stateline.org. Follow Stateline on Facebook and X.