Trevor Hawkins, an attorney at Legal Aid of Arkansas, remembers how hectic his job became when the state temporarily imposed work requirements on Medicaid recipients: his office was flooded with frantic phone calls from people saying they couldn’t comply with the new rule because they didn’t were healthy enough to work or had to care for sick relatives.

“A whole bunch of people, after a month or two, started getting messages saying, ‘Hey, you’re not in compliance, and you’re going to lose your coverage,'” Hawkins told Stateline. For many people, he said, the maintaining their coverage “absolutely critical to maintaining their health or getting better so they can work again.”

In June 2018, Arkansas became the first state to require certain Medicaid recipients to work, volunteer, attend school or participate in job training to receive benefits. At the time a federal judge stopped politics in April 2019, 18,000 adults had lost coverage.

Arkansas was one of 13 states which was authorized to impose work rules on at least some Medicaid recipients during the last Trump administration. Another nine states sought permission to adopt Medicaid work requirements during Trump’s term but had not won approval by the time it ended.

When the Biden administration took office, it revoked all approvals. But now that Trump is back, many of those states will try again—and they’ll have a supportive U.S. Congress in their corner.

Republicans push work requirements for coverage under Missouri Medicaid expansion

Republicans on Capitol Hill are eager to find ways to pay for extended tax cuts enacted during Trump’s first term, and Medicaid — funded jointly by the federal government and states — is on the horizon.

Requiring states to establish Medicaid work rules, as many Republicans would like to do, would reduce federal spending by an estimated $109 billion over a decade, according to the Congressional Budget Office. That’s because the cost for about 900,000 people would be shifted entirely to states, while another 600,000 people would become uninsured, CBO estimated. About 72.4 million people are enrolled in Medicaid.

Arkansas renewed its efforts even before Trump’s victory. Last year, Republican Gov. Sarah Huckabee Sanders requested federal approval from the Biden administration to apply work rules to able-bodied adults covered by the state’s Medicaid expansion under the Affordable Care Act, who are enrolled in health plans that Arkansas Medicaid buys for them on the state’s health insurance exchange. That application is pending.

Missouri Republicans have pushed for Medicaid work requirements repeatedly over the years, most notably after voters overwhelmingly approved expanding the program’s eligibility 2020. That effort was briefly renewed earlier this year as part of a battle between Senate Republicans over renew taxes that fund Missouri’s portion of Medicaid.

Georgia, after winning a legal battle with the Biden administration, already have work requirements in place for people covered by its partial expansion of Medicaid. And Idaho, Mississippi, Oklahoma, South Dakota and Tennessee have pending requests to require at least some of its Medicaid recipients to work.

Supporters say requiring Medicaid recipients to work, study or train for a career gives them a boost toward self-sufficiency and financial stability. Kristi Putnam, Secretary of the Arkansas Department of Human Services, said in a statement announcing her state’s latest request that it would challenge people to “embrace economic opportunities that can lead to real advancement at work.”

“Meaningful work connects people with purpose — and through the pandemic, we’ve seen negative effects on mental health from people who feel disconnected,” Putnam said.

However, critics argue that such rules end up hurting far more people than they help. In a 2020 study When researchers from the Harvard TH Chan School of Public Health examined how work requirements worked in Arkansas, they “found no evidence that the policy succeeded in its stated goal of promoting work and instead found significant evidence of harm to health care coverage and access.”

More than 95% of the Arkansas beneficiaries the researchers surveyed already met the work requirement or should have qualified for a waiver. The main reason people lost coverage, the researchers found, was because they had trouble verifying they were following the rules. Many of those who lost their coverage stopped taking their medications, delayed care and ended up in medical debt.

“Our findings should provide a strong signal of caution for federal and state policymakers considering work requirement policies in the future,” the researchers concluded.

Under the rules Arkansas put in place during the first Trump administration, Medicaid participants were under the age of 50 had to report that they spent at least 80 hours each month working, attending school, in job training or volunteering. The rule only applied to people who became eligible after Arkansas expanded Medicaid under the ACA to cover adults making up to 138% of the federal poverty level.

And people were exempt if they were pregnant, had a child under 18 at home, were disabled, had to care for a person who couldn’t care for themselves, were in alcohol or drug treatment, or were in school or job training full time.

About 70,000 of the approximately 270,000 Arkansans on Medicaid were subject to the new rules, and about 1 in 4 of them lost coverage.

Unlike Arkansas, Georgia has not expanded Medicaid under the Affordable Care Act. But its Pathways to Coverage Programwhich launched in July 2023, allows people with household incomes up to 100% of the federal poverty level who are not already eligible for Medicaid to enroll in the program if they meet work requirements. Georgia’s qualifying activities and waivers are similar to those Arkansas had.

Fiona Roberts, spokeswoman for the Georgia Department of Community Health, told Stateline that as of Nov. 15, there were 5,548 people enrolled in the program and a total of 7,518 people had been enrolled at some point — evidence, she said, that the program is helping people walk from Medicaid to private insurance.

But in the first year, Pathways to Coverage only registered approximately 4,200 people — many fewer than 25,000 the state had predicted. The the cost of the program by the end of 2023 was $26.6 million, and more than 90% of that went to administrative and consulting costs, according to KFF, a nonprofit health research group. If Georgia had opted for a full expansion under the ACA, the federal government would have picked up 90% of the tab and the state would have covered approximately 359,000 people.

Leah Chan, director of health care at the Georgia Budget and Policy Institute, said work requirements are especially challenging for people living in rural areas.

“If you don’t have broadband internet at home, you won’t be able to upload the documentation and your payslips,” Chan told Stateline. “Even eligible people can’t keep up, especially in rural areas where there are additional barriers to participation.”

Benjamin Sommers, a professor of health care economics at the Harvard TH Chan School of Public Health and one of the authors of the Arkansas study, said the experience with work requirements there and in Georgia should give other states pause.

“All that ended up happening was people lost coverage because of red tape, became uninsured, and in some cases we saw they had less access to health care,” Sommers said.

But Arkansas Republican state Rep. Aaron Pilkington, who serves on his House Health Committee, said the Medicaid work rules are “100% on the table and something we will look to request from the Trump administration.”

“They can find work and get better health insurance through their employer,” Pilkington said. He said the volunteering and training options make the rules even more attractive.

Meanwhile, in some of the 10 states that have not expanded Medicaid under the ACA, imposing work requirements may be the only political way to get expansion over the finish line.

“Most of the Democrats that I’ve talked to didn’t want the work requirements, but to get it through the Mississippi Legislature, it will most likely have one,” Sam Creekmore told Stateline.

“We’ve looked at Georgia’s plan. We recognize the pitfalls and hopefully learn from mistakes.”

The Independent’s Jason Hancock contributed to this story.

Statesline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact editor Scott S. Greenberger with questions: (email protected). Follow Stateline further Facebook and X.