Medicaid Work Requirements and Access to Health Care

The Centers for Medicare & Medicaid Services (CMS) mandate under the One Big Beautiful Bill Act requires certain able-bodied, working-age adults to complete 80 hours each month of employment or other qualifying activities to maintain their Medicaid health coverage. States must implement the Medicaid Community Engagement Requirement no later than January 1, 2027. Federal grants and private-sector technology vendors are expected to help states implement the requirements by identifying which beneficiaries are subject to the mandate and which meet exceptions, verifying compliance, enforcing the requirement against beneficiaries who do not comply or whose compliance cannot be verified, and submitting data to CMS regularly.

The mandate aims to increase employment, reduce government spending, and improve program integrity. Evidence from states such as Arkansas and Georgia, which previously implemented Medicaid work-reporting requirements, suggests that these measures may fail to meet those goals and may even be counterproductive. These results may reflect several factors, including that most affected Medicaid beneficiaries already work or otherwise qualify for exemptions, limiting policymakers’ ability to increase employment through marginal reforms. Losing health coverage may also undermine individuals’ ability to obtain or maintain employment by reducing access to necessary medical care.

Scholars have shown that administrative burdens associated with implementing work requirements—including reporting obligations, documentation requirements, and verification procedures—can affect whether eligible individuals maintain health coverage. Some experts define administrative burdens as “onerous experiences people encounter when interacting with public services,” including the bureaucratic hurdles and paperwork common in the process of applying for social welfare programs. Under CMS’s new Medicaid work requirements, enrollees would either have to demonstrate compliance when applying for coverage and at least every six months after, or prove that they qualify for an exception. This process may become more difficult because of duplicative documentation requirements and more restrictive views on self-attestation for conditions such as medical frailty.

Whether administrative burdens result from an inadvertent side effect of policy or from deliberate design, they are likely to reduce Medicaid coverage on a large scale, particularly affecting vulnerable populations such as sick patients, those with limited internet access, and caregivers whose responsibilities may be difficult to document. A gap exists between meeting Medicaid work requirements and successfully navigating the reporting system, placing thousands of Americans at risk of losing access to health care.

In this week’s Saturday Seminar, scholars discuss the consequences of administrative requirements on Medicaid coverage and provide recommendations to reduce coverage loss among eligible beneficiaries.

• In an article in the Houston Journal of Health Law & Policy, Robert I. Field of the Kline School of Law examines how administrative requirements shape Medicaid enrollment and retention. Drawing on evidence from the post-pandemic Medicaid unwinding, Field shows that many beneficiaries lose coverage because of procedural barriers rather than substantive ineligibility. To reduce these coverage losses, he proposes automatic enrollment based on tax returns and participation in other safety-net programs, as well as automatic transitions between Medicaid and Affordable Care Act Marketplace plans. Field recommends that policymakers concerned with Medicaid access should focus less on eligibility restrictions and more on minimizing administrative obstacles to enrollment and renewal.
• In an article in the Administrative Law Review, Pamela Herd and Donald Moynihan of the Ford School of Public Policy and Rutgers Law School’s Amy Widman explain why administrative requirements can prevent eligible individuals from accessing public benefits. Herd, Moynihan, and Widman identify learning, compliance, and psychological costs as barriers that discourage participation and increase disenrollment. Herd and her coauthors illustrate why Medicaid work requirements often produce coverage losses: beneficiaries must understand reporting rules, repeatedly document compliance, and cope with the uncertainty and stress of maintaining eligibility. The Herd team highlights how Medicaid work requirements may lead to coverage losses when reporting and verification systems impose burdens that eligible beneficiaries cannot easily satisfy.
• In an article in Inquiry, Michael Folse and James Bridges of Shreveport School of Medicine and Anthony DiGiorgio of UCSF Health examine work requirement policies in federally administered social welfare programs such as Medicaid to assess their impact on employment and health outcomes. Using examples of Medicaid work requirement programs in Arkansas, Georgia, California, and Utah, and data from non-health insurance programs such as the Supplemental Nutrition Assistance Program (SNAP), Flose and his coauthors find that work requirements are most successful when paired with employment assistance. Drawing on this evidence, they propose a federal Medicaid work requirement that incorporates work-support programs to improve both employment and health outcomes.
• In an article in The BMJ, Pritzker School of Medicine student Daniel Johnson and several coauthors use a statistical analysis to estimate the impact of a work requirement program implemented as part of Georgia’s 2023 Medicaid expansion. Comparing Georgia with surrounding states that did not implement similar requirements, the Johnson team concludes that the Georgia program had no significant impact on Medicaid coverage, the uninsured rate, or employment. Johnson and his coauthors compare the results of their study to similar research addressing Medicaid work requirements and highlight the important policy implications of their findings—work requirements may ultimately be counterproductive because they reduce Medicaid coverage without any positive impact on employment.
• In a report for the Commonwealth Fund, MaryBeth Musumeci of the Milken Institute School of Public Health and several coauthors recommend that Congress adopt continuous eligibility and automated renewal policies to reduce Medicaid churn. Churn occurs when people lose and regain coverage within a year, resulting in coverage gaps, the Musumeci team explains. Musumeci and her coauthors identify continuous eligibility as an effective countermeasure that reduces churn by 30 percent. They further assert that continuous eligibility would reduce state Medicaid costs by tens of millions of dollars, as disenrollment and reenrollment costs hundreds of dollars for each person. The Musumeci team also recommends expanding automated renewal systems and offering renewal assistance to increase continuous coverage.
• In a National Bureau of Economic Research (NBER) working paper, Rebecca Myerson of Rollins School of Public Health, Laura Dague of the Bush School of Government and Public Service, and Allison Espeseth of NBER argue that reducing administrative barriers to Medicaid keeps eligible individuals covered by increasing renewals and reducing procedural denials. Myerson and several coauthors find that administrative frictions cause non-renewal and procedural denials in eligible populations. From their field experiment, the Myerson team contends that sending prerecorded calls reminding Medicaid recipients to renew coverage is a low-cost measure to reduce coverage loss. The Myerson team notes, however, that inaccurate contact information limits these calls’ effectiveness and that reducing administrative requirements offers a more reliable way to maintain coverage.