A push by the federal government and some states to require certain Medicaid beneficiaries to work in order to maintain eligibility for benefits has run into a series of roadblocks, both in the courts and in state legislatures. 

The push began in January 2018, when the Trump administration released guidance to state Medicaid programs permitting them, for the first time, to experiment with requiring beneficiaries to work in order to maintain medical benefits. The guidance specified that states could not impose work requirements on people with disabilities, pregnant women, minor children, the elderly and people enrolled in schools. 

Although the federal guidance exempts people with disabilities from the work requirements, advocates remain concerned that many people with disabilities will not be protected. While the guidance expressly exempts people receiving Social Security disability benefits or who are institutionalized, the guidance provides little direction to states as to who else would be protected. 

States seeking to add work requirements are required to first obtain approval from the federal Department of Health and Human Services (HHS). Later in January 2018, HHS approved a plan for Kentucky, allowing the state to require Medicaid beneficiaries to complete 20 hours of work a week in order to keep receiving benefits.

In June 2018, the U.S. District Court for the District of Columbia blocked Kentucky's plan from going into effect, saying that the plan exceeded HHS's authority under the Medicaid Act. After HHS approved a new and different plan for Kentucky, the same district court blocked Kentucky's new plan from going into effect on March 27, 2019. 

In contrast, work requirements went into effect in Arkansas in June. In the subsequent six months, an estimated 18,000 people lost coverage as a result. 

Arkansas program, like Kentucky's proposed program, was put on hold by the Court's March 27 decision. 

In the decision, the court focused on whether the plan met the express goal of the Medicaid Act: to expand health insurance coverage for low-income populations. As the court saw it, HHS, in approving the work requirements plans for Kentucky and Arkansas, failed to consider the likely loss of coverage for a significant number of beneficiaries. 

By Kentucky's own estimate, submitted in its application to HHS, some 95,000 people would lose Medicaid coverage over five years due to the imposition of the work requirements. 

“[The] Secretary never adequately considered whether Kentucky HEALTH would in fact help the state furnish medical assistance to its citizens,” the court wrote, referring to Kentucky's program.

The Trump administration is appealing the decision. 

Despite this setback, HHS and some states are pushing ahead with efforts to impose work requirements. In its annual budget proposal, released in March 2019, HHS recommended that all state Medicaid programs implement work requirements. 

HHS has also approved work plans for Arizona, Michigan, Ohio and Utah. However, legislation requiring state Medicaid agencies to seek HHS approval of similar programs has failed in West Virginia, Wyoming and Iowa. 

To read a report from Center on Budget and Policy Priorities on Medicaid work requirements, click here.