The Trump administration granted approval for 13 states to implement work requirements for Medicaid, linking eligibility to employment. However, only Arkansas was able to successfully implement this program. Before a U.S. District Court judge halted the program in 2019, over 18,000 individuals were removed from the Medicaid rolls in Arkansas. The Biden administration then revoked the approvals for these requirements in all states, effectively stopping similar efforts across the country.

However, the Supreme Court, which did not hear the matter, now has an additional conservative justice. This gives certain Republicans optimism that their proposal, if accepted during a potential second term for Trump, would succeed.

Ohio state Senator Steve Huffman, who serves as the Republican chair of the Senate health committee, believes that this current Supreme Court is more likely to support work requirements.

The conservative organizations, including the Heritage Foundation, have created a plan for the 2025 presidential election.

According to Nina Owcharenko Schaefer, who is the director for the Heritage Foundation’s Center for Health and Welfare Policy, the recent actions by states regarding work requirements show ongoing support for the policy and may prompt a potential future administration under Trump to reconsider it.

Schaefer stated that the actions of the [states] demonstrate their proactive approach, rather than remaining passive and observing the situation. This sends a message to Congress and the incoming administration that they are still committed to pursuing this matter and are hopeful to resume its progress.

However, certain conservatives, including past members of the Trump administration, are hesitant to revisit the discussion on work requirements, believing it may not be worth the potential difficulties. This could lead to another round of lengthy legal battles, diverting the attention and effort of federal health officials from other important matters.

“According to Brian Blase, a previous member of the Trump administration and current president of the conservative Paragon Health Institute, the implementation of Medicaid work requirements was a major focus at HHS but ultimately unsuccessful. Given the court’s ruling and other pressing issues, Blase questions the effectiveness of repeating this approach. He also notes that even if Trump were to be re-elected, work requirements are not guaranteed.”

Not all Republican governors support the current initiative. Representatives for Tennessee Governor Bill Lee and Oklahoma Governor Kevin Stitt stated that their states are not currently implementing work requirements. Utah’s Medicaid agency reported no progress on this policy since 2021. The office of Virginia Governor Glenn Youngkin did not provide a comment.

However, numerous Republicans view the decrease in enrollment and cost savings as advantageous outcomes of the policy. According to the Congressional Budget Office, implementing a federal work requirement would lead to 1.5 million individuals losing federal funding for their healthcare coverage, resulting in a savings of $109 billion for the federal government over 10 years.

The suggested plans differ, but typically mandate that Medicaid beneficiaries work 80 hours per month, or engage in schooling, volunteering, or other community activities — with exemptions for specific individuals such as pregnant women, disabled persons, or senior citizens.

The Democratic party contends that a large number of individuals who have signed up for Medicaid are employed, and implementing a proof requirement will only add more paperwork obstacles to an already complicated program, increasing the likelihood of individuals slipping through bureaucratic gaps.

However, Republican lawmakers are primarily promoting this policy as a means of incentivizing individuals to enter the workforce, as many states struggle with low rates of labor participation. However, it should be noted that these rates are higher among individuals aged 25 to 54, the demographic that many of these states are aiming to reach.

Huffman expressed hope that this initiative would help address the issue of unemployment. He emphasized the importance of following rules in order to receive benefits, and stated that this is the most effective way to encourage individuals to find employment and eventually transition off of Medicaid.

The most recent budget for Ohio stipulates that the state must once again seek approval from the federal government in February to implement work requirements. This is despite an appeal for the state’s 2018 plan that is still pending with federal health officials. According to Dan Tierney, a representative for Republican Governor Mike DeWine, the administration will continue to support the implementation of work requirements, even if it was not mandated by the budget.

Currently, Arkansas is the most advanced state in terms of implementation. In 2019, Governor Sarah Huckabee Sanders, who previously served as Trump’s press secretary, instructed the state’s Medicaid agency to request a work requirement waiver. However, this request is still awaiting approval from CMS since June.

Gavin Lesnick, a representative for Arkansas’ Medicaid agency, stated that this plan aims to provide opportunities for those who have gained Medicaid coverage through expansion to transition from relying on government insurance to achieving financial self-sufficiency by obtaining private marketplace or employer-provided health insurance.

Several other Republican governors have also announced comparable plans. Idaho Governor Brad Little’s budget proposal, which was revealed in January, contains provisions for work requirements.

A representative for Governor Henry McMaster of South Carolina informed POLITICO that the governor would “definitely” push for the policy if a Republican is elected as President. Governor Jeff Landry of Louisiana has shown a willingness to consider work requirements, but did not allocate funds for the policy in his budget.

In Missouri and South Dakota

Lawmakers plan to propose a ballot measure in November that would seek voter approval for work requirements. The two states previously expanded Medicaid through a constitutional referendum and can only make changes to the program through another ballot measure.

In January, the Republican supermajority Senate of South Dakota voted to add the proposal to the ballot. The sponsor of the measure, Crabtree, predicts that it will pass through the House at a swift pace.

The majority of voters showed strong support for the expansion of Medicaid. After it was approved on the ballot, we have been diligently putting Medicaid expansion into action in South Dakota,” he explained. “We are simply going back to the voters to seek clarification.”