Late last year, the Trump administration announced its intention to permit states to apply for waivers to their Medicaid programs that would allow them to require that nonexempt Medicaid recipients be employed to get their Medicaid benefits.1 On January 11, the Centers for Medicare and Medicaid Services (CMS) released a letter explaining how states could apply for the waivers.2 At least 10 states, including Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, Mississippi, New Hampshire, Utah, and Wisconsin, have filed work waivers,3 and by mid-February, Indiana and Kentucky saw their requests approved.4, 5 The work requirements for both states will go into effect later this year.

While the proposals vary by state, generally they would require Medicaid beneficiaries to work, volunteer, attend school, or be engaged in a job search or a job training program for a certain number of hours per week. In Kentucky and Indiana, the work requirement will be for 20 hours each week.4, 5 States are expected to allow some exceptions-Kentucky and Indiana, for example, have exemptions for pregnant women, people who are medically frail, and students, among others.4, 5

More bureaucracy, more obstacles to coverage. Health advocates are concerned that paperwork and financial requirements could force people out of Medicaid, leaving them without health care coverage. That's because even people who fulfill the required number of work and work-equivalent hours can lose coverage for a month or more in both Kentucky and Indiana if they fail to pay their premiums or fail to file paperwork if their work status changes.4, 5 Taking a financial literacy class can restore benefits in Kentucky, but health advocates worry that for some people, especially those with cognitive disabilities, the new requirements could be confusing. "Adding obstacles to health care[horizontal ellipsis] ignores an abundance of social science research concluding that the types of restrictions approved will limit enrollment in the Medicaid program, spurring uninsured rates and throwing vulnerable families into poverty or closer to poverty," said Leonardo Cuello, health policy director at the National Health Law Program in Washington, DC, in a statement.6

A spokesperson in the governor of Kentucky's office, in a phone call with AJN, estimated that the new rules would end Medicaid coverage for about 95,000 people in Kentucky. In Indiana, the number of people losing coverage is likely to be smaller but still in the tens of thousands, partly because some people may find jobs that pay too much in wages to allow them to qualify for Medicaid.7 Health advocates are concerned that people who are no longer eligible for Medicaid based on income may not make enough money to afford private health insurance and will be left with no coverage. They also point out that the majority of people receiving Medicaid already work or are unable to work because of illness or caregiving responsibilities. According to a study published in 2017 by the Kaiser Family Foundation, about 60% of people receiving Medicaid are already working and about 30% cannot work because of disability or caregiving obligations.8, 9 There's also concern that many people who are eligible for Medicaid may be confused by the new requirements and not apply.

The 'deserving' and 'undeserving' poor. Conservative lawmakers and think tanks generally support the idea of work requirements and say that polls they've taken indicate many voters do as well. "Reforms like work requirements will help break the cycle of dependency and preserve funds for the truly needy and other critical public services," said Tarren Bragdon, chief executive officer and president of the Foundation for Government Accountability.10

ANA: work requirement a 'major step backward.' The American Nurses Association (ANA) spoke out strongly against the new proposal. "Work requirements for able-bodied adult Medicaid beneficiaries would likely have little to no positive impact on employment and could even negatively impact both access to health care and employment prospects for Medicaid beneficiaries," said Pamela Cipriano, PhD, RN, NEA-BC, FAAN, president of the ANA, in an e-mail to AJN. "[This move] represents a major step backward from achieving the ANA's principles of health system transformation. We urge the administration and Congress to put an end to these attempts to score political points while undermining health care and coverage for all Americans."

Concerns about the impact of the CMS allowing work requirements for Medicaid recipients stretch beyond the need to look for and keep a job. In Kentucky, the proposal also includes premiums of $1 to $15 per month for some beneficiaries, based on income,11 a seemingly low fee that many beneficiaries with limited monthly funds may nevertheless find too steep, causing some to opt out of the program and remain uncovered.

The first lawsuit against the Kentucky work requirements was filed by 15 Medicaid beneficiaries in the state in January.12 The suit argues that the new requirements violate the authority of the U.S. Department of Health and Human Services-which runs the CMS-because the main objective of Medicaid is to provide health coverage. Kentucky's governor, Matt Bevin, has said that if a court challenge keeps the state from imposing a work requirement, he will simply end the Medicaid expansion in his state to achieve his goal of reducing the number of people covered by-and cost to the state of-Medicaid.4 In Kentucky, 400,000 people were added to Medicaid under the Medicaid expansion provisions of the Affordable Care Act.

"Waivers should enhance coverage and improve the delivery of care," says Judith Solomon, vice president for health policy at the Center on Budget Policies and Priorities in Washington, DC, in a recent report.13 "They shouldn't let states make changes to Medicaid that hurt beneficiaries by causing them to lose coverage or make it harder for them to get health care."-Fran Kritz

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