waiting in line

A status update on the Medicaid work requirement landscape

Earlier this week, Michigan submitted a proposal to the Trump administration requesting approval to impose work requirements on Medicaid expansion beneficiaries. Michigan’s proposal was submitted through the Medicaid Act’s section 1115 waiver program, which allows states to introduce experimental projects that “further the objectives” of the Act. (For a more in-depth discussion of the function of section 1115 waivers in the Medicaid scheme, see Carmel Shachar’s Bill of Health post from earlier this summer.)

Work requirement waivers garnered a rush of attention after the Trump administration issued guidance indicating that it would begin approving such requests. Michigan is now one of twelve states that have submitted a work requirement proposal, with four of those states having successfully received approval from HHS.

This recent development in Michigan provides an opportunity to take stock of the Medicaid work requirement landscape since the Trump administration began approving the waivers.

First, it is important to note what is not included in the Michigan waiver proposal. Michigan’s state legislature made headlines earlier this year when its senate passed a bill exempting Medicaid beneficiaries living in counties with high unemployment from its proposed work requirement scheme. The senate bill was widely critiqued for its projected discriminatory impact on Michigan’s black Medicaid beneficiaries, who are significantly less likely to live in the counties that would have been subject to the exception.

Legal experts suggested that such a policy, if enacted, could be challenged on the basis of Title VI of the Civil Rights Act, which prohibits discrimination on the basis of race by recipients of federal funds and allows for disparate impact challenges. After Governor Rick Snyder suggested that he would not sign a bill containing the exception, the provision was removed in the final version. But while Michigan ultimately rejected this exception, Kentucky, Ohio, and Michigan have been implementing similar approaches to their work requirement programs. The question of legal challenges to the discriminatory implementation of work requirement waivers may thus remain an open one.

Second, Michigan’s proposal was submitted at a moment when litigation surrounding work requirement waivers is heating up. As Carmel Shachar describes in her blog post, a federal district court judge vacated Kentucky’s work requirement approval on the grounds that the waiver was arbitrary and capricious, in violation of the Medicaid Act’s stated purpose to provide medical assistance to residents of partner states. Last month, Arkansas’s program was challenged on the same grounds in a suit filed by several advocacy groups. As these cases wend their way through the courts, they will inevitably reshape the scope of Section 1115 waivers.

Third, new research on the topic of Medicaid work requirements has supplemented policy arguments against the waivers. Two studies on the topic of Medicaid work requirements were published in JAMA on the same day that the Michigan waiver request was submitted. Both studies, one from a team at Yale School of Medicine, the other from a group at Cambridge Health Alliance, found that the policies would have little impact on Medicaid beneficiaries, most of whom already work. This new research suggests that work requirements would make a minimal dent in public spending, cutting into one rationale for the waivers. And, as data from Arkansas’s recent work requirement roll-out shows, the schemes may impose substantial bureaucratic barriers on those who qualify for Medicaid under the work requirements.

These studies add to a body of pre-existing evidence showing that Medicaid work requirement waivers are not supported on robust policy grounds. The Trump administration’s guidance suggested that work requirements are health-promoting, citing evidence that unemployment is associated with a range of deleterious health effects. But this premise rests on a correlative, rather that causal, relationship, and—as an executive summary from the Center on Budget and Policy Priorities points out—the argument ignores the fact a lack of health care access is detrimental to health. Moreover, analogues in other welfare programs, including SNAP, show that the argument that work requirements result in an increase in employment is faulty.

As states continue to submit waiver requests to impose work requirements on Medicaid beneficiaries, lawsuits and policy inquiries will continue to percolate. As Sara Rosenbaum for the Commonwealth Fund notes, the role of evidence like the studies described above in these legal challenges may be an important one.


Alexandra Slessarev is a 2018-2019 Petrie-Flom Center Student Fellow

Alexandra Slessarev

Alexandra Slessarev

Alexandra Slessarev graduated from Harvard's joint JD/MPH program in 2019, and she will be clerking for Judge Ronald Lee Gilman on the 6th Circuit beginning in August 2019. Her Petrie-Flom fellowship paper was entitled "Curbing Pharmaceutical Detailing Practices in the Opioid Era." Alex's public health research interests include maternal and reproductive health, state-level Medicaid implementation, and the intersection of health and the environment. Prior to starting her dual-degree program, Alexandra spent a year working as a research assistant at the Bixby Center for Global Reproductive Health at the University of California, San Francisco, where she worked on several projects related to long-acting reversible contraception provision and education.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.