Medicaid Work Requirements: A Prescription for Laziness?

Authored By: Kendall Eddington Art By: Sophia Li Since unemployment is associated with poor health, could requiring Medicaid recipients to show proof of work lead to healthier Americans and spending cuts? In 2018, the Trump Administration was the first in Medicaid’s history to require proof of work to receive Medicaid coverage, also referred to as work requirements [1]. These requirements applied to non-elderly, non-pregnant, and non-disabled adult beneficiaries. The Biden Administration reversed these waivers and blocked states from enacting further work requirements, but with Trump back in office, Republican states are eager to reinstate work rules for Medicaid to cut federal spending. The Congressional Budget Office estimated that around 40 percent of Medicaid beneficiaries, or 600,000 people, would become uninsured and that $109 billion would be saved over a decade [2]. That price tag may seem appealing, but the reality is that these requirements are ineffective at promoting workforce participation and the large coverage losses are due to administrative complexity.

Republicans like Speaker Mike Johnson argue that work requirements are “common sense” due to the narrative that welfare beneficiaries are lazy and wasting government spending [3]. They also believe that work requirements will motivate unemployed beneficiaries to find employment that may include private health insurance. Both of these facts will lead to less federal spending. So have work requirements promoted workforce participation? In short, no. In states that have implemented work requirements, there was no correlation with increased employment. For example, Arkansas fully implemented a work requirement in 2018. The requirement included at least 80 hours of work per month, with exceptions for pregnant or disabled individuals. Failure to comply led to a revoke of coverage. Approximately 18,000 individuals lost their coverage during this time, but not because they were unemployed—rather, they lost coverage because they struggled to submit complex paperwork to prove their employment status [4]. Another independent evaluation on Georgia’s work requirements found that technology issues particularly impacted beneficiaries, including lack of access to reliable internet and laggy portals [5]. The complex employment reporting system burdens Medicaid enrollees who are more likely to have less reliable access to the internet and technology due to their income status. In addition, over the 18 months that Arkansas work requirements were in place, no significant changes to employment or other community engagement activities were observed in the target population [4].

Contrary to many myths on free riders in social programs, most Medicaid enrollees who are capable of working are already working [6]. In 2023, 92 percent of Medicaid enrollees were either working full or part time, or not working due to caregiving, illness, disability, or school attendance. It is also important to note that Medicaid provides services to assist people with disabilities to work, and therefore disqualifying disabled people from Medicaid due to their lack of employment will make their workforce participation much harder or impossible. Medicaid work requirements do not increase workforce participation because enrollees are largely already working, disenrollment may make it harder for disabled individuals to maintain work, and because state evidence has demonstrated disenrollments are due to paperwork issues rather than unemployment.

Even with these disenrollments, work requirements still cost states money. States actually spend more enforcing these requirements than they save due to administrative costs in processing the associated paperwork. According to the Government Accountability Office, Kentucky’s proposed work requirements would lead to administrative costs exceeding $270 million [7]. In Georgia, their work requirement program cost over $26 million, with 90 percent of the budget spent on administrative rather than medical services [5].

Medicaid’s objectives are to provide coverage for health and related services to low-income and disadvantaged populations. So does reducing coverage through barriers to enrollment follow Medicaid's objectives? The problem lies in framing social programs like Medicaid as unnecessary welfare services that promote “public charges,” or individuals dependent on government assistance. Instead of pushing for policies like work requirements that promote the narrative that Medicaid users are lazy and using up federal spending, policymakers should focus on reducing the systemic barriers to economic success.

Works Cited

1. Guth, M., & Musumeci, M. (2022, May 3). An Overview of Medicaid Work Requirements: What Happened Under the Trump and Biden Administrations? KFF. https://www.kff.org/medicaid/issue-brief/an-overview-of-medicaid-work-requirements-what-happened-under-the-trump-and-biden-administrations/

2. ‌Sommers, B. D., Goldman, A. L., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2019). Medicaid Work Requirements — Results from the First Year in Arkansas. New England Journal of Medicine, 381(11), 1073–1082. https://doi.org/10.1056/nejmsr1901772

3. Seitz, A., Demillo, A., & Freking, K. (2025, February 18). Republicans consider cuts and work requirements for Medicaid. AP News. https://apnews.com/article/medicaid-cuts-work-requirements-congress-republicans-90ec1119f1d95de067c76f79eec7fa87

4. ‌Sommers, B. D., Chen, L., Blendon, R. J., Orav, E. J., & Epstein, A. M. (2020). Medicaid Work Requirements In Arkansas: Two-Year Impacts On Coverage, Employment, And Affordability Of Care. Health Affairs, 39(9), 1522–1530. https://doi.org/10.1377/hlthaff.2020.00538

5. Rayasam, A. M., Renuka. (2024, March 20). Georgia’s Medicaid Work Requirements Costing Taxpayers Millions Despite Low Enrollment. KFF Health News. https://kffhealthnews.org/news/article/georgia-medicaid-work-requirements-experiment-high-cost-low-enrollment/

6. Tolbert, J., Cervantes, S., Rudowitz, R., & Burns, A. (2025, February 4). Understanding the Intersection of Medicaid and Work: An Update | KFF. KFF. https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work-an-update/

7. ‌Office of Accountability. (2019). Medicaid Demonstrations: Actions Needed to Address Weaknesses in Oversight of Costs to Administer Work Requirements. Gao.gov. https://www.gao.gov/products/gao-20-149