A federal policy guidance document released by CMS in January 2018 showed states how to implement Medicaid work requirements, sparking a wave of proposals from Republican-led state legislatures to require certain enrollees to complete work or community engagement activities. Some states have already garnered federal approval, while others are waiting for authorization, though the results of the midterm elections will likely halt or stop these efforts in approximately half of states that have submitted waivers.
Approved or in effect:
Arkansas: Arkansas became the first U.S. state to implement Medicaid work requirements in June 2018, and since then more than 8,462 recipients have been disenrolled for failing to report qualifying work activities, or about 18% of the approximately 46,000 beneficiaries who are subject to the program. The Medicaid and CHIP Payment and Access Commission recently expressed concern about this rate in a letter to the Department of Health and Human Services and recommended that disenrollments in the state be put on pause while the program is improved, raising the question of potential federal intervention. Incumbent Republican Gov. Asa Hutchinson—a staunch defender of the program—held on to his position in the state’s midterm elections, so it is likely that the program will be defended against any action from the federal government or courts.
Wisconsin: On November 1, the Trump administration approved Republican Gov. Scott Walker’s proposal to require childless adults ages 19-49 on Medicaid to work for more than 80 hours per month. Walker had proposed that if they fail to work, train for a job, or participate in other activities for a period of four years or longer, they would lose coverage, have to pay small monthly premiums, and reapply in six months. But with the election of Democrat Tony Evers pushing Walker out of office, it is likely that this proposal will be withdrawn or changed. One aspect of it that may remain is full coverage of residential centers for substance use disorder treatment under Medicaid.
Kentucky: Even if Evers hadn’t won the governor race in Wisconsin, it is likely that Walker’s work requirement proposal would have been rejected by a federal judge, as is the case in Kentucky. Led by Republican Gov. Matt Bevin, the state was the first to file to propose Medicaid work requirements after the Trump administration’s initial encouragement in January. After submitting this proposal, a judge struck it down and sent it back to HHS for modifications, arguing that it has to prove that adding work requirements improves health outcomes and outline how the plan would help the state finance medical assistance. Unlike Wisconsin, Bevin was not up for reelection in the midterms, so there is still a chance the work requirements could be put into action if the judge is satisfied with the changes.
Indiana: Republican Gov. Eric Holcomb was not up for reelection this year, so Indiana’s work requirements remain set to take effect in 2019. Unlike other programs, Indiana is taking a more lenient, phased-in approach to implementation to give enrollees time to find work. For example, there will be a six-month grace period from the time the requirements take effect. After the grace period, the hourly requirement will be increased incrementally over one and a half years. Enrollee compliance will only be reviewed once a year. Aside from that, Indiana’s program is similar to Kentucky’s and mandates nondisabled adult enrollees work an average of 80 hours a month. Three groups have sued in federal court to block the implementation.
New Hampshire: Republican Gov. Chris Sununu was reelected, keeping the state’s work requirement program on track to effect in January 2019. New Hampshire’s program appears to be the strictest among those that are both approved and pending. For enrollees subject to the rule, the state will require more work or other eligible activity (self-employment does not count) per month than other states at 100 hours. It also does not exempt all parents with children—only parents with children under 6. Enrollee compliance will be reviewed monthly.
Kansas: Democrat Laura Kelly upset incumbent Republican Gov. Kris Kobach in Kansas, raising questions about the future of Medicaid work requirements in the state. Political considerations may win out, however—Kelly wants to expand Medicaid within her first year in office, and to gain approval for that, she may need to back the state’s waiver in order to assuage Kansas’ Republican-dominated state legislature.
Arizona: Since March, Arizona’s waiver for Medicaid work requirements has been waiting for approval from the federal government. The state has been trying for years to impose work requirements and was rejected in 2016 by the Obama administration. These efforts were led by Republican Gov. Doug Ducey, who was recently reelected in the midterms.
Maine: Like Wisconsin and Kansas, a Republican governor supporting Medicaid work requirements has been ousted by a Democrat in the midterms. The new Governor, Janet Mills, is likely to reject the state’s pending work and community engagement requirement and instead expand Medicaid.
Mississippi: Mississippi reworked its work requirement program proposal in May order to gain approval from CMS after advocacy groups pointed out a catch-22 that would have disenrolled recipients who gained employment for making too much income. Mississippi’s Republican governor was not up for reelection, so this revised program—if approved—will be likely to take effect in the future.
North Carolina: North Carolina’s waiver for Medicaid work requirements is relatively vague, not including specifics on how many hours individuals must work or penalties for non-compliance. That may be because the state is requesting approval preemptively—if the waiver is approved, the legislature would still need to vote on whether to implement a program.
Utah: Utah voters approved a ballot initiative to fully expand Medicaid, superseding a more limited expansion the state had planned to move forward with in 2019. That limited expansion also included a waiver to apply work requirements to Medicaid, but it is unclear if the ballot initiative supersedes this as well.
Ohio: Republican Mike DeWine defeated Democrat Richard Corday, sustaining the momentum for work requirements in Ohio that commenced with the state’s previous Republican governor.
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