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work requirements
As House GOP Reelects Johnson as Speaker, Coalition Says Hands Off Medicaid
Hundreds of advocacy organizations warned lawmakers that "enacting Medicaid cuts would betray your constituents of all political affiliations who are seeking more economic security, not less."
Jan 03, 2025
As Rep. Mike Johnson won reelection as House speaker on Friday, a broad coalition of more than 300 advocacy organizations warned the incoming Republican-controlled Congress against cutting Medicaid amid reports that the GOP is eyeing work requirements and other damaging changes to the program that provides healthcare coverage to around 80 million Americans.
In a letter to the congressional leaders of both parties, Families USA, the AFL-CIO, the American Federation of Teachers, Doctors for America, the NAACP, and other national and state-level organizations wrote that "cutting Medicaid was not a budget solution that American families asked for" during the 2024 election cycle.
"Doing so now would betray your constituents of all political affiliations who are seeking more economic security, not less," the groups continued. "Cutting Medicaid would shift costs and administrative burdens onto working-class families, states, and health systems. Proposals to cap funding, reduce the federal share of Medicaid spending, establish block grants, institute work reporting and community engagement requirements, cut state revenue from provider taxes, or otherwise undermine the fundamental structure of the Medicaid program all have the same effect."
"If instituted," they added, "Americans will lose access to lifesaving services, states will be strapped with massive budget holes, hospitals and clinics will lose revenues and be forced to cut staff and scale back services, and American families and workers will be unable to afford essential care and get sicker—leading to a loss in productivity and the economy suffering as a result."
"The American people are watching... and we urge you to take this opportunity to choose a different path: one that secures our country's health and economy."
The letter was sent as House members gathered on the floor of the chamber and voted to keep Johnson (R-La.) as speaker in the new Congress.
Once members are sworn in, Republicans are expected to pursue a massive tax-cut package that they will seek to fund by slashing key social programs, including Medicaid.
GOP lawmakers have discussed imposing work requirements on Medicaid recipients as part of a broader effort to offset the enormous costs of another round of tax cuts that would disproportionately benefit the wealthy and large corporations.
The Congressional Budget Office has estimated that Medicaid work requirements, which typically entail difficult-to-navigate bureaucratic procedures, would cause roughly 600,000 people to lose insurance.
Shortly after the November election, The New York Timesreported that "some Republican legislators are interested in even more sweeping changes, such as turning Medicaid into a block grant program, which would keep federal costs fixed even if more people sign up for coverage."
Edwin Park, a research Professor at the Georgetown University McCourt School of Public Policy's Center for Children and Families, warned in a November blog post that turning Medicaid into a block grant program would be "deeply harmful."
"To compensate for the severe federal funding cuts resulting from block grants," Park wrote, "states will either have to dramatically raise taxes and drastically cut other parts of their budget including K-12 education or, as is far more likely, institute deep, damaging cuts to Medicaid eligibility, benefits, and provider and plan payment rates."
"That includes not just dropping the Medicaid expansion, which covers nearly 20 million newly eligible parents and other adults, but gutting the rest of state Medicaid programs that serve tens of millions of low-income children, parents, people with disabilities, and seniors," Park continued.
In their letter on Friday, the advocacy coalition reminded congressional leaders that "millions upon millions of Americans rose up" in opposition to the GOP's failed attempt to cut Medicaid in 2017.
"The American people are watching once again," the groups wrote, "and we urge you to take this opportunity to choose a different path: one that secures our country's health and economy."
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Here's Why We Know Work Requirements for Medicaid Don't Work
And let's not forget how cruel they are.
Dec 21, 2024
As Republicans at the federal level prepare to take over majorities in both the House and Senate, some have proposed deeply damaging cuts to Medicaid, including taking health coverage away from people who don’t meet unnecessary and burdensome work requirements. Some state policymakers are interested in pursuing Medicaid work requirements as well. But a Georgia Medicaid program provides the latest evidence that work requirements are the worst sort of red tape — blocking health coverage for working people, people with serious health conditions, and people with disabilities.
Georgia is one of ten states that has not adopted the Affordable Care Act’s Medicaid expansion provision, instead applying for a waiver to provide Medicaid to certain low-income adults, conditioned on meeting work requirements. This waiver program, called Pathways to Coverage, requires adults with low incomes to report at least 80 hours of work or volunteer activities each month as a condition of getting and keeping their coverage. It is available to adults up to 100 percent of poverty, or $15,060 annually for an individual.
The results from over one year of Pathways to Coverage are in:
- About 5,500 people were covered as of November 2024, far less than the 110,000 who initially expressed interest, and well under the about 240,000 uninsured people estimated to potentially be eligible for Pathways.
- Application backlogs, excessive paperwork, and complex rules have left people waiting for coverage after they’ve applied and kept many other people from even applying for the program.
- Spending on administrative changes, such as systems updates, eclipsed spending on health care services and offered little return on investment in facilitating enrollment.
Work requirements prevent people from accessing health care for reasons that are outside their control. For example, many people working low-paying jobs are at the mercy of employers who can reduce their hours without notice. Family emergencies, inconsistent childcare, or sudden illnesses can also disrupt a person’s ability to work. Furthermore, people with disabilities and chronic illnesses are not exempt from the Pathways reporting requirements. They could face challenges finding enough hours to work because employers will not provide reasonable accommodations or their health conditions restrict the amount of time they can work. As a result, people are at risk of not receiving often life-saving health coverage.
Previous work requirement proposals conditioned continuing Medicaid coverage on reporting enough eligible work, or other qualifying activity, hours. Georgia’s Pathways program adds an additional hurdle: requiring work reporting at the time of application, which creates a complex process that deters eligible people from even applying. In June 2024, 42 percent of the people who expressed interest in applying for Pathways were not considered to have a complete application because they did not complete a report showing any number of qualifying activity hours. And among those who did have complete applications, 19 percent were denied due to reporting fewer than the required 80 hours per month or insufficient verification of hours.
Focus groups conducted by Georgia Budget and Policy Institute and Creative Research Solutions back up this data. Pathways applicants pointed to challenges getting support during the enrollment process, technology issues with the enrollment system, or frustrations with getting denied due to paperwork issues and having to wait to have the application checked again.
Georgia is among the slowest states to process Medicaid applications due to excessive bureaucratic strain. Others didn’t feel comfortable applying because they were concerned they would not get approved, likely due to the complex process and the high denial rate in the first year. The frustration with paperwork issues and the stress from not having health coverage are similar to findings from focus groups in Arkansas, the first state to implement a Medicaid work requirement temporarily in 2018.
And although only a small fraction of eligible people have enrolled, the program has cost about $13,360 per enrollee in combined state and federal Medicaid spending through the end of the first year. That’s significantly more than the about $2,490 per enrollee Pathways was initially estimated to cost in the first year. About 35 percent of spending went toward covering care, but most went to systems modifications to implement work reporting. And in August 2024, the state separately spent $10.7 million on an outreach campaign, directing millions to consultants while hundreds of thousands of people are still without insurance.
From the standpoint of ensuring access to health care and improving efficiency, it is clear from Georgia that work requirements do neither. Once again, the Pathways program shows us that work requirements are simply a way to keep people from getting health care by requiring them to navigate a complicated system to report work hours or claim exemptions. This is especially cruel because the few people who made it through the process and secured Medicaid coverage through Pathways reported being able to get lifesaving care, medications, and other health tools to manage or prevent long-term illnesses.
Even though Georgia sought to use this program as an alternative to expanding Medicaid, the same lessons would apply in states that already expanded coverage. Policymakers should reject work requirements, which leave people with higher health care costs and state agencies with increased burden.
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Georgia Medicaid Debacle Bolsters Progressive Case Against Work Requirements
"While state politicians continue playing games with people's lives, Georgians are dying because they can't afford the healthcare they need," said Sen. Raphael Warnock.
Dec 26, 2023
An effort by the Republican-led Georgia government to partially expand Medicaid is falling well short of enrollment expectations, a failure that could stem from the program's burdensome work requirements and other administrative barriers that are abundant in a for-profit system that doesn't guarantee healthcare to all as a right.
Politico reported Tuesday that just 1,800 people enrolled during the program's first four months—leaving the state on pace to miss Republican Gov. Brian Kemp's target of 31,000 enrollees within the first year.
"Critics blame the paltry expansion on an overly complex program with too many hurdles for people to clear," the outlet noted.
Brendan Duke, senior director for economic policy at the Center for American Progress, wrote in response to Politico's reporting that "a large part of progressive opposition to work requirements in safety net programs isn’t principle—it's about the paperwork that prevents working people from enrolling in programs they qualify for."
"Great example with Georgia and Medicaid here," Duke added. "Work requirement supporters will ask, 'Why do you oppose work reqs if the vast majority of people would still qualify?' Some of the problem is you're denying support to people who can't find a job. But some of it is you're functionally denying support to people with a job!"
As Georgia began rolling out its Pathways to Coverage program earlier this year following a legal fight with the Biden administration, researchers at Georgetown University's Center for Children and Families (CCF) argued that the state's insistence on a work requirement would likely box many people out, including workers with irregular hours and parents who lack access to childcare.
The work requirements in Georgia's program do not include an exemption for caregiving or high childcare costs, the CCF experts noted. As such, they warned, "many parents will likely remain uninsured under the Pathways program especially parents of babies and toddlers who are preschool age."
Georgia, which has one of the highest uninsured rates in the U.S., is currently the only state with a Medicaid work requirement in effect—though it's not the first to ever implement one.
In 2018, with the approval of the Trump administration, Arkansas put in place work mandates for Medicaid with disastrous results. Before the policy was blocked in federal court, more than 18,000 people in the state were thrown off Medicaid in just seven months for failing to adhere to the requirements.
The Arkansas policy did not boost employment, an outcome consistent with research showing that work requirements are only effective at stripping people of benefits.
"Pathways to Coverage has cost Georgia more money and covers far fewer people than if the state simply joined 40 other states in expanding Medicaid."
In 2021, the Biden administration rescinded Trump-approved waivers that had allowed Georgia and other states to add work requirements to their Medicaid programs. Georgia challenged the decision in court and prevailed last year, thanks to its argument that the experiment would lead to more people receiving coverage than if the program were blocked.
Kemp has suggested that around 345,000 Georgians could be eligible for the expanded Medicaid program, but the state expects that just around 64,000 will eventually enroll in the program.
That's just 14% of the people who would be covered if Georgia joined nearly every other U.S. state in fully expanding Medicaid under the Affordable Care Act, CCF researchers estimated earlier this year.
In addition to covering fewer people than full Medicaid expansion, Georgia's experiment is also expected to cost the state far more.
Leah Chan, senior health analyst at the Georgia Budget and Policy Institute, told a local Georgia newspaper earlier this year that Pathways to Coverage will cost roughly $2,420 per enrollee. Full Medicaid expansion, by contrast, would run the state just $496 per enrollee, as the federal government pays much of the cost.
Sen. Raphael Warnock (D-Ga.) told Politico that "Pathways to Coverage has cost Georgia more money and covers far fewer people than if the state simply joined 40 other states in expanding Medicaid."
"While state politicians continue playing games with people's lives," he added, "Georgians are dying because they can't afford the healthcare they need."
Heightened scrutiny of Georgia's Medicaid experiment comes as states across the U.S. are rapidly conducting eligibility checks and kicking people off Medicaid en masse following the end of pandemic-era protections. Georgia is one of nine Republican-led states that collectively account for 60% of Medicaid and Children's Health Insurance Program disenrollments this year.
An overwhelming majority of the disenrollments nationwide have been for procedural reasons, such as a paperwork error.
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