Medicaid Work Requirements: Is Momentum Stalling?

Last week marked the 18-month anniversary of CMS guidance urging states to apply for Section 1115 Medicaid waivers to impose work reporting requirements as a condition of eligibility. One day after issuing the guidance (January 12, 2018) CMS approved the first state, Kentucky, to go forward with work reporting requirements along with numerous other harmful changes such as coverage lockouts.

CMS leaders have repeatedly touted work reporting rules as one of the centerpieces of their Medicaid policy despite clear evidence from Arkansas, the only state to implement so far, that more people were becoming uninsured (more than 18,000 lost their Medicaid coverage) and the policy was failing to achieve its purported objective of encouraging employment.

Last week also saw New Hampshire’s Republican Governor Sununu sign a bill modifying that state’s very harsh work rules that would have soon resulted in thousands being notified that they were going to lose their coverage as of August 1st.

And given that in March a federal judge remanded both Kentucky and Arkansas’s waivers in two linked cases, which are now pending appeal, as of this writing the good news is that no one is losing their health insurance as a result of this misguided approach.

So far, nine states have received approval from CMS to impose work reporting requirements. Virginia has a request pending that might be approved this summer. Six more states (AL, MS, OK, SC, SD, TN) have requests pending that are even more troubling as they are all non-expansion states, which means these policies will only harm the very poorest families with children. I have blogged about this before, and I hope everyone is paying close attention as to whether CMS will cross this line. You can read more here about why this is so harmful to the poorest families.

However, on the positive side, there are clear signs that the momentum may be stalling. New Hampshire’s Governor was clearly having second thoughts – either about cutting thousands of people off for no good reason, or because NH’s court date is looming (currently scheduled for July 23rd with Judge Boasberg – the same judge who issued the stays in the Arkansas and Kentucky cases), or both.

And last week we learned that Arizona has submitted a request to CMS to alter the state’s implementation plan to phase it in by county and reportedly push back from January 1 2020 as their approved waiver documents state to “summer/early fall” of 2020. (See p. 58 of the state’s presentation for the list of counties.)

The remaining states that have approved waivers but have not yet implemented their work requirements include:

  • Indiana, which is next up but moving relatively slowly (reporting requirements took effect this month but the first coverage losses would begin in January);
  • Michigan and Wisconsin, which have both had Democratic Governors elected since the waiver approvals and are less enthusiastic about implementation (in fact Governor Evers (D-WI) recently vetoed administrative funding to implement Wisconsin’s work requirement and other barriers to coverage);
  • Ohio, which is not scheduled to implement until January 2021.[1]

So, eighteen months after CMS rolled out its work reporting requirements initiative with much fanfare, I am happy to note that no one is losing coverage as a result of this misguided approach.



[1] Utah has a job search requirement rather than a work activities reporting requirement approved and scheduled to begin on 1/1/20.


Joan Alker is the Executive Director of the Center for Children and Families and a Research Professor at the Georgetown McCourt School of Public Policy.