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Work requirements in Medicaid expansion programs are back on the agenda in many statehouses — despite their lackluster track record.
In Mississippi, the idea has momentum from GOP lawmakers advancing legislation to expand Medicaid. In Kansas, the Democratic governor proposed work requirements to try to soften Republican opposition to expansion. (She’s had little luck, so far.)
The controversial policy even has fresh traction in states that expanded Medicaid years ago, including Idaho and Louisiana.
Just two states have implemented a special program to require low-income adults to prove they’re working in exchange for health coverage under Medicaid. In 2019, a court ended Arkansas’s initiative, but not before 18,000 people lost coverage.
Since then, only the signature Medicaid experiment of Georgia Gov. Brian Kemp (R), called Pathways to Coverage, has survived legal challenges and gotten off the ground.
Yet it’s off to a rocky start, with low enrollment and mounting administrative costs already exceeding $20 million. “It doesn’t work, and it’s perfectly clear in Georgia,” said Joan Alker, executive director and co-founder of the Georgetown Center for Children and Families.
Only about 3,500 people have enrolled so far. That’s a small fraction of the Georgians who would be eligible if the state adopted the Affordable Care Act’s Medicaid expansion without work requirements.
Some Georgia Republicans blocked a bill in March that would have authorized a full Medicaid expansion, arguing that Pathways needs more time. The program is just one part of an overall plan to move people into private insurance, Kemp spokesperson Garrison Douglas told us.
Work requirements can come with big administrative price tags, according to a 2019 report from the Government Accountability Office, which recommended that the Centers for Medicare & Medicaid Services consider administrative costs in waiver applications.
States have to set up technology to check compliance, plus hire staff to keep all the paperwork straight. Under Georgia’s plan, people earning up to the federal poverty level — $15,060 for an individual adult — must document that they’re working, in school, doing community service or performing other qualifying activities. Taking care of a child or parent doesn’t count.
Documents obtained by KFF Health News show that administrative costs along with consulting fees have absorbed more than 90 percent of the Georgia program’s spending. As of Dec. 31, about $2 million went to Medicaid managed-care companies; $24 million was spent on administration and consultants. The administrative costs are expected to balloon to $122 million over four years.
Critics argue that the red tape keeps people from getting health care. And while work requirements don’t significantly boost employment, simply providing health coverage can, according to a 2023 KFF brief.
But don’t expect the idea to disappear — especially if former president Donald Trump returns to the White House. The first Trump administration approved Medicaid work-requirement programs in 13 states.
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