As they work to pass a “big beautiful bill” filled with tax cuts and spending reductions, Republicans in Congress are proposing adding work requirements to Medicaid, the $618 billion program that provides health care to more than 70 million low-income Americans.
“When so many Americans who are truly in need rely on Medicaid for life-saving services, Washington can’t afford to undermine the program further by subsidizing capable adults who choose not to work,” GOP Rep. Brett Guthrie, chairman of the House Committee on Energy and Commerce, wrote in an op-ed last week. “That’s why our bill would implement sensible work requirements.”
As the name implies, work requirements are rules that force people to work in order to receive a government benefit. They have been in use for decades as part of other programs, most notably cash welfare assistance, but have never been used nationally for Medicaid. Only one state, Georgia, currently has work requirements for Medicaid. Arkansas had them briefly at the end of the last decade, but the policy was struck down by the courts.
The GOP’s draft proposal would establish a nationwide “community engagement requirement” that would mandate Medicaid recipients to work, volunteer or attend school for at least 80 hours per month to maintain their benefits. It includes many exceptions that would allow pregnant women, new mothers, anyone under 19 and members of certain other groups to keep their coverage without working.
The goal
Work requirements have been a popular solution to concerns about freeloading in government programs since at least the 1980s. Supporters see them as a crucial step toward putting people on a path to supporting themselves and as a tool to weed out those who aren’t willing to put in the effort to improve their circumstances.
In the 1990s, then-President Bill Clinton signed a bill establishing nationwide work requirements for cash welfare as part of what he called “a crusade to transform our system of welfare into a system of work; to transform a system of dependence into a system of independence.”
That logic is still convincing to most Americans today. Well over half of respondents (62%) said they support work requirements for Medicaid in a poll taken earlier this year by the health care research group KFF.
Despite how common this perception is, the overwhelming share of evidence we have from the real world suggests that work requirements don’t make people more self-sufficient and create barriers that cause even those who do work to lose benefits they are eligible for.
The reality
Study after study over the decades has found that work requirements — whether they’re for Medicaid, food assistance or cash welfare — don’t have a meaningful effect on employment. A recent government report that looked at the effects of work requirements on Temporary Assistance for Needy Families, the program more commonly known as welfare, found that after nearly three decades, the policy had “little effect on employment” but had “substantially reduced the number of people receiving the benefits they provide.”
A different study on work requirements for food assistance, commonly known as food stamps, found similar results: Employment rates weren’t affected, but hundreds of thousands of people lost access to support they relied on to eat.
Medicaid work requirements haven’t been tried at a wide scale, but research into the more limited attempts suggests that results are similar. Arkansas imposed its own “community engagement” rules in 2018. The policy was only in place for 10 months, but in that span 18,000 people in the state lost health coverage and the rules “did not increase employment,” one study found. Georgia’s Medicaid work requirement system, which has been in place since 2023, has been plagued by low enrollment, technical glitches and ballooning administrative costs.
Two years ago, the nonpartisan Congressional Budget Office released an estimate of the impact that nationwide work requirements for Medicaid would have. It found that the policy would cause 1.5 million Americans to lose their health care coverage and would have “a negligible effect on employment status or hours worked.”
Why work requirements don’t work
One of the main reasons that work requirements don’t increase employment is because most people who get government benefits are already working or are unable to work. About 92% of Medicaid recipients under the age of 65 are either employed or unable to work because of disability, illness, caregiving responsibilities or school obligations, according to KFF.
A donut chart showing the employment status of Medicaid recipients, with 92% either working or unable to work because of their circumstances.
There is also research showing that adding extra paperwork steps — like requiring people to certify with the government that they are in fact working — can create bureaucratic pitfalls that cause even those who have satisfied all of the new criteria to lose their benefits.
“Work requirements impose administrative barriers and red tape that lead to coverage losses among both people who are working as well as people the policies purport to exempt,” Gideon Lukens and Elizabeth Zhang of the Center on Budget and Policy Priorities wrote earlier this year.
Many critics of work requirements say the policy is built on the false belief that people who are struggling to get by are in that position because of laziness or some other personal shortcoming.
“More stringent work requirements implemented in the past have largely failed to boost work in significant ways because these requirements do not attack the core problems of weak macroeconomic conditions, the volatile nature of low-wage work, and other barriers to work,” Hilary Wething of the Economic Policy Institute wrote in January.
Will the work requirements become law?
Republicans are attempting to combine a laundry list of legislative priorities into a single, massive spending bill that they hope to pass before Memorial Day. With narrow majorities in both houses of Congress and zero reason to expect they will get any Democratic votes, they have very little room for error. Any part of the bill could be changed or scrapped altogether if the party can’t unify behind it.
Medicaid work requirements have been a point of disagreement in negotiations within the party, but so far there has not been vocal opposition to imposing them. In fact, the main critique has come from hard-line conservatives who want them to go into effect sooner than they would in the initial proposal.