By Jennifer M. Haley, Genevieve M. Kenney, Eva H. Allen, and Michael Karpman
Work requirements in Medicaid are on the agenda at the federal level and in multiple states, despite evidence that they increase uninsurance without boosting employment. Medicaid provisions approved by the House Energy and Commerce Committee as part of budget reconciliation include a mandatory work requirement for adults eligible for expansion coverage under the Affordable Care Act. The policy would, likely starting in 2027, require that adults ages 19 to 64 participate in 80 hours of work or specified work-related activities for one or more months preceding application for the program and one or more months between eligibility redeterminations (now mandatory every six months) while enrolled, unless they qualify for an exemption for reasons such as pregnancy or a disability that keeps them from working. Georgia’s Pathways to Coverage program, enacted under a Section 1115 waiver, is the only current Medicaid program with work requirements. Pathways applicants and enrollees must submit documentation of work activities to both enroll in and maintain coverage.
Although the Medicaid work requirement provision currently under consideration in Congress would exempt parents, guardians, and caretaker relatives living with dependent children, it does not require that states provide automatic exemptions based on parental status or other characteristics. If states do not provide for automatic exemptions, parents who do not submit a request to be exempted on that basis could still lose coverage under the requirement.
Federal policy changes targeting expansion adults could affect millions of parents with Medicaid expansion coverage. Although data on expansion enrollment for the estimated 9.7 million noncustodial parents are unavailable, information on their incomes suggests that many could be eligible for Medicaid expansion coverage as well. Policies that lead to a loss of Medicaid coverage among parents would have adverse effects on their access to needed care, financial security, and health outcomes, which in turn would have harmful effects on their children.
Medicaid work requirements would lead to large coverage losses
Recent Urban Institute research assessed potential coverage losses for Medicaid expansion enrollees ages 19 to 64 under a federal work requirement along the lines of the Limit, Save, Grow Act passed by the House in 2023. Like the Energy and Commerce Committee’s proposal, that bill would have exempted parents living with dependent children from the work requirement, but it did not require states to do so automatically. Assuming states would use available data to automatically exempt people who had earnings above a specified threshold, parents living with a dependent child, and those complying with existing Supplemental Nutrition Assistance Program (SNAP) work requirements, the analysis found that an estimated 5.5 to 6.3 million adults ages 19 to 64 not living with dependent children would lose Medicaid coverage in 2026—even though about 9 in 10 expansion enrollees who would be subject to work requirements are already engaged in activities prescribed under the policy or have characteristics that should exempt them from the requirement.
But the current congressional proposal would go further, requiring Medicaid applicants to have already been meeting the work requirement to initially enroll, not just stay enrolled, similar in a number of ways to Georgia’s Pathways program. Under the bill, applicants would have to be identified by the state as having satisfied the requirement for one or more consecutive months preceding application (as determined by the state, without any limit for the lookback period). Moreover, states would be given the option to require reverification of compliance with the work requirement as often as every month between eligibility redeterminations. Although the draft legislation does not specify how applicants and enrollees would satisfy the work requirement—with the Secretary setting additional criteria for such verification—they could be required to submit documentation like Pathways applicants. The very low enrollment in the Georgia program suggests that coverage losses under the Energy and Commerce bill would be even larger than under the Limit, Save, Grow Act because the red tape and other enrollment barriers associated with the Pathways enrollment process as well as additional barriers would be extended nationwide.
Even if parents are intended to be exempt from work requirements, many still could lose coverage because of misinformation, system errors, and administrative burdens
Evidence from previous Medicaid work requirements highlights the critical role of data-matching so states can automatically deem individuals exempt from or compliant with requirements without necessitating action on the part of the beneficiary. In Arkansas and New Hampshire, which briefly began implementing work requirements in 2018 and 2019, respectively, the vast majority of people who could maintain their enrollment were identified as exempt or compliant by the state using available data. But most people who were not automatically deemed exempt or compliant lost coverage or were at risk of losing coverage despite working or potentially qualifying for an exemption. Studies found that many people did not satisfy the work reporting requirement because of factors like lack of awareness, confusion about the policy, and difficulties navigating reporting systems.
Under the House Energy and Commerce Committee proposal, states are only required, where possible, to automate verification processes for work or work activities, but they are not required to implement automatic exemptions, including for parents. Moreover, some states may lack the capacity to provide automatic exemptions to all parents living with dependent children in any event. Although states’ Medicaid applications generally collect information on whether an adult is living with a dependent child, we know from the recent unwinding of the pandemic-related Medicaid continuous coverage requirement that data available to states are not necessarily complete or readily accessible, that state databases are not always updated regularly, and that errors happen.
This would likely be a particular problem for guardians and caretaker relatives. In a scan of states’ Medicaid applications, we found that only some collect information on whether a person lives with any children for whom they are the main caretaker, which could be used to determine caretaker status. This means many states would be unlikely to provide automatic exemptions on this basis even if they intended to do so. And other guardians and caretaker relatives may not have been identified as such when applying. Thus, families would have to navigate complex reporting requirements to verify their exemption status. Misinformation about work rules could also cause some parents, guardians, and caretaker relatives to believe they would have to demonstrate work effort to qualify, which could keep some from even trying to enroll.
Work requirements could also affect other adults in children’s lives
Even if parents, guardians, and caretaker relatives living with dependent children were automatically exempted from work requirements or even if some are otherwise able to obtain exemptions, the policy could affect other important adults in children’s lives. To date, work requirement proposals have not included explicit exemptions for noncustodial parents. Other adults in households with children (e.g., parents’ spouses and partners, siblings over 18, nonelderly grandparents, and other family members) could lose coverage, risking the financial security of the entire household. Coverage instability among other adults who have regular contact with children, like child care providers, could also disrupt children’s lives.
Coverage losses among parents and other adults would harm children, their families, and their communities
Children’s healthy development and overall well-being depend on the health and stability of their parents and other adults in their lives. Losing coverage under Medicaid work requirements would reduce parents’ access to care, worsen their health, and create more stress and worry, which could adversely affect parents’ mental health and that of their children. Coverage loss among parents would also affect families’ financial stability, potentially causing them to incur medical debt and experience greater financial hardship that can harm children’s well-being immediately and into adulthood. And given evidence of “welcome mat” effects—when health insurance coverage gains among parents increase the likelihood that their children are also covered—coverage losses among parents could similarly mean that fewer children will be covered.
Work requirements would also increase states’ administrative spending. And adverse effects would likely extend to states’ economies and health care providers, including hospitals, since treating more patients without insurance would saddle them with greater levels of uncompensated care—weakening communities’ health care infrastructure, including for meeting children’s health care needs.
Medicaid work requirements don’t work for families
Work requirements would not help families make ends meet amid other threats to their health and well-being: prior studies assessing the effects of Medicaid work requirements in Arkansas found that they increased uninsurance with no improvement in employment. Families could also face greater challenges meeting basic needs given the proposed significant expansion of SNAP work requirements for millions of adults living with children ages 7 and older, which would reduce assistance to help families afford groceries. The Medicaid work requirement provisions in the House Energy and Commerce Committee’s proposal also would not provide any new funding for job training or job search programs or ameliorate other barriers to work that parents face, such as lack of transportation or difficulties finding affordable and high-quality child care.
Medicaid work requirements may not target children directly. But available evidence suggests that they could still cause significant harms for children and their families.
The authors are researchers at the Urban Institute, a nonprofit research organization. They would like to thank Joan Alker, Edwin Park, and Tim Waidmann for helpful feedback on this blog.