As readers of the SayAhhh! Health Policy blog know, states that have taken up the Affordable Care Act’s (ACA) Medicaid expansion are now mandated to impose a punitive work reporting requirement as of January 1, 2027. Florida has not taken up the expansion and covers very few adults, but Florida legislators are considering a bill that requires the state to file a Section 1115 demonstration waiver to apply a work reporting requirement to an undefined group of “able-bodied adults” ages 19-64. The only adults in Florida that would come close to meeting this term would be parents with income below $597 a month for a family of three and 19-20 year olds.
On Feb. 10, the Florida Senate Committee on Health Policy, chaired by Senator Don Gaetz, approved SB 1758 on an 8-3 vote. The bill has other provisions that are reasonable; but the Medicaid work reporting requirement is not. The relevant language begins on p. 6 with the stated intent that a work requirement is necessary to ensure that Medicaid is “a sustainable resource for residents who are most in need of such assistance”. What follows is a long list of exemptions that mirrors the federal list of exemptions in H.R. 1, which enacted the largest cuts to Medicaid in history as part of President Trump’s budget bill last year.
With respect to parents, those with children under age 14 are exempt, theoretically speaking (we will explain below why this is not a given), and the legislative language states that parents with children between the ages of 14 and 18 would only need to work during school hours. The House companion bill, HB 1453, is more restrictive and only exempts parents with children under age 6.
There are many reasons why this is a terrible idea but let’s start by focusing on this fatal flaw—in a state like Florida that has not taken up the ACA Medicaid expansion to cover all adults up to 138% of the poverty line such a policy would mean that very low- income parents and young adults are damned if you do and damned if you don’t. If you don’t meet the work reporting requirements, you lose your Medicaid for noncompliance, but if you work the number of hours required by the bill, your income would be too high to qualify, and you lose your Medicaid.
The majority of low-wage jobs don’t offer affordable employer-sponsored insurance, and Florida’s Medicaid coverage gap means these parents will be left without any pathway to affordable health insurance.
Moreover, assuming the Senate version prevails, this is a very small group of parents that would be subject to the new requirements (the bill analysis says that 111,789 people would be impacted, but it is not clear how this number is derived), but would engender very complex new administrative requirements to be developed and require redeterminations for these parents every 6 months. These new complex eligibility rules would have to be added to the state’s largely online system, most likely through a contract with the state’s vendor, Deloitte, which has a terrible track record in Florida and will likely cost the state a lot of money. As we’ve written about many times, the neighboring state of Georgia imposed a work requirement, also administered through a contract with Deloitte, costing the state more than $50 million in administrative costs over 4 years – only to cover about 8,000 people. In Georgia, two-thirds of public funds expended on its waiver have gone to Deloitte.
Don’t assume the exemptions will work smoothly. Remember how just a few years ago Florida officials claimed that all was going fine with the Medicaid unwinding? We were doubtful about those dubious claims at the time and a recent scathing court order pulls back the curtain on just how much was going wrong with the process – including the fact that a mind-blowing 1 million calls were summarily dropped in just two months. (p.92) The phone system was constructed in such a way so as to avoid looking bad on required reporting of call center wait times to the federal government. Despite blocking 54% of the calls received, wait times still often exceeded an hour, and Medicaid beneficiaries were left without support from the state to decipher the “incomprehensible” notices they received terminating their Medicaid coverage.
Another problem is that parents who should be exempt may not be aware of that fact and not apply in the first place. Medicaid is the largest source of coverage for low-income parents in Florida. Of parents with incomes below 26% of the federal poverty level (Florida’s Medicaid limit for parents, which is $597 a month for a family of three), 57% rely on Medicaid for their health insurance. About 14% of parents below 26% FPL are already uninsured.[1] Considering Florida’s unwinding performance, we’re not optimistic that if the policy were to be adopted the state would adequately inform parents that they may be exempt and the uninsured rate would rise even among parents of younger children.
If adopted, the bill would have one more obstacle to face in this expensive endeavor to take coverage away from some low-income parents, and it’s a big roadblock. The new federal law does not permit the imposition of work reporting requirements in states that do not offer expanded coverage. H.R. 1 (the federal budget package approved last year) does not allow states to impose work reporting requirements in states that have not done expansion or have an expansion-like group covered through a Section 1115 demonstration (think Georgia and Wisconsin here). Florida has no such group – and these very poor parents described above, who would be subject to the work reporting requirement in SB1758, are a mandatory coverage group known as Section 1931 parents, and H.R. 1 specifically does not allow work requirements for such mandatory coverage groups. The expansion group is effectively an optional group.
The bottom line is that H.R. 1 does not allow states like Florida to impose work requirements on mandatory non-expansion populations, and it does not allow waivers to break those rules. Florida’s legislature seems to be ignoring this key fact, but budget estimators should add more litigation costs to the ledger of taxpayer dollars that would be wasted. But the fatal flaw is that this performative proposal creates a Catch-22 for very poor parents who will just become uninsured. The only winners will be the vendor who gets the contract to make the eligibility system changes and the lawyers hired to defend the indefensible maneuver and send the bill to the Florida taxpayers.
[1] Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2024 American Community Survey (ACS) data accessed through IPUMS USA, University of Minnesota. Children and Families analysis of U.S. Census Bureau 2024 American Community Survey (ACS) data accessed through IPUMS USA, University of Minnesota.