Also, work requirements haven't worked in states where they've been tried.GOP motto: The cruelty is the point.Two years ago, [Georgia] introduced a similar version of Medicaid work requirements as part of a new initiative called “Pathways to Coverage,” which made Georgia’s Medicaid program available to low-income people who didn’t qualify for the state’s traditionally narrow guidelines.
[...]
Lots of eligible people have no idea the new program exists. But two independent assessments—one by a state contractor, one by an independent research organization called the Georgia Budget and Policy Institute—found that a bigger obstacle were the kind of paperwork issues that bedeviled Corporal and Seaborn, and that can be even tougher for the people who need Medicaid the most.
“They may not have access to consistent internet, their phone number may not be active if they’re not able to pay their bill that month,” Leah Chan, a researcher at the Georgia Budget and Policy Institute who conducted that organization’s assessment. “They may be moving a lot because of the high cost of rent and low housing stock. So there’s a lot of issues that can make it more challenging.”
Nothing about Georgia’s experience should have been surprising, because pretty much the same thing happened in 2018 when Arkansas introduced work requirements—not for a new group it was trying to enroll, as Georgia did, but for people already on the program. More than 18,000 beneficiaries lost coverage over a span of ten months, as the state systematically purged people who had not made it through the verification process.
Harvard researchers examining the data later estimated that more than 95 percent of the target population actually satisfied the Arkansas work requirements, meaning they were not just eligible but legally entitled to coverage. Behind those numbers were befuddled applicants who couldn’t make their way through the verification process or got rejected for unexpected reasons, ending up uninsured and, in some cases, stuck with medical bills they couldn’t pay.
A federal judge in early 2019 put a stop to the Arkansas program, on the theory that the effects were incompatible with Medicaid’s basic purpose of promoting health care access for the poor. That legal rationale would disappear under the new Republican bill, which would not merely permit work requirements but make them mandatory.
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But while the Republican bill would apply work requirements only to those people with incomes above the poverty line who are part of the “expansion” population—meaning those states that made Medicaid more widely available after 2010, using extra funding from the Affordable Care Act—it would include everybody in that group up to age 65. An earlier version of the bill stopped at age 55, on the theory that low-income people older than 55 tend to have a harder time finding work, and are more likely to have infirmities making work more difficult. But by bumping up the age they produced bigger budget savings, though more people are losing coverage.
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But advocates and experts say a bigger factor is the difficulty so many Medicaid beneficiaries have documenting their status—especially because, Georgetown Research Professor Leonardo Cuello told me, the current legislation includes a “look back” provision allowing states to disqualify applicants who haven’t maintained the minimum hours for a month or two or even six or twelve prior to applying.
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“They often have informal employment arrangements—they don’t have pay stubs they can show you, maybe they’re doing work in their neighborhoods,” he went on to explain. “You have a lot of people who are low-wage shift workers, who cannot control their hours. They wish they could be guaranteed a reliable, steady income. But every month, they find out from their employer how many shifts they’re going to get. And, you know, income just changes every month based on that.”
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And then there are questions about the exemptions—which, in theory, are there for those “vulnerable” populations that Republicans on Capitol Hill keep saying they want to protect.
In practice, advocates and analysts told me, documenting care for somebody other than a child, or demonstrating a disability making it impossible to work can prove difficult for a population in which people are more likely to have poor access to and knowledge of technology, not to mention inconsistent or unreliable housing and phone service.
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In 2019, Michigan Democratic governor Gretchen Whitmer tapped him to run the state’s department of health and human services, and one of his biggest jobs was implementing a work requirement Michigan Republicans had enacted years before.
The state invested heavily in data systems, call centers, and outreach, as part of a broader effort to streamline public services. Even so, the best estimates suggested that more than one in seven Medicaid beneficiaries in the state—more than 100,000 Michiganders—would lose Medicaid in the process.
It never happened because of a court ruling similar to the one that shut down the Arkansas experiment. But to Gordon, it was proof that the expense, difficulty, and collateral damage of imposing work requirements are simply not an effective use of state resources—and that, as he wrote in a recent Commonwealth Fund paper, “the Americans who lose insurance through no fault of their own will suffer the most.”
The Bulwark
You might be forgiven if you think taxing the uber-wealthy would be a simpler and more fruitful effort.
UPDATE 05/25/2025:
UPDATE 06/11/2025:
