In 2018, the Trump Administration attempted to radically change Medicaid by allowing states to impose “work requirements” for Medicaid enrollees. Not only was this act unprecedented and unlawful, it threatened the very health and economic security of women, families, and LGBTQ+ people by obstructing access to Medicaid through confusing and administratively burdensome work reporting requirements. These requirements wrongfully stripped eligible enrollees of their Medicaid coverage1 and perpetuated the myth that individuals enrolled in Medicaid are unemployed or unmotivated to work.

Medicaid work reporting requirements hurt people who need health care the most, with loss of coverage increasing the likelihood of worse health, medical debt, and economic instability,2 and these requirements would devastate tens of millions if imposed nation-wide.3 Unfortunately, this may soon become a reality.

To pay for billionaires’ tax breaks and emboldened by President Trump’s cruel agenda to limit federally funded programs,4 Republican lawmakers are proposing enormous cuts to Medicaid through so-called “work requirements.”5 Under the guise of “increasing employment,” these lawmakers plan to drastically restrict health care access for individuals and families with low incomes—all to pass even more tax cuts for the wealthiest and big corporations. Meanwhile, women, children, and families need access to affordable health care now, more than ever, as poverty rates continue to increase.6 But instead of helping low-income and working families, Republican lawmakers are prioritizing big corporations and the wealthiest people.

Work reporting requirements conflict with the core objectives of Medicaid and are unlawful.

At its core, Medicaid exists to provide health coverage to people with low incomes who cannot otherwise afford it, which helps these individuals attain or retain the capacity for independence and self-care.7 Work reporting requirements go against these objectives – allowing a state to define what it means for an individual to be working and to deny Medicaid coverage to certain adults that do not meet their narrow definition. Importantly, the Medicaid statute does not condition receipt of Medicaid benefits on any qualifications beyond those in the statute that serve to show an individual is someone who is in need of assistance obtaining health care coverage and services.

Indeed, previous attempts at implementing work reporting requirements have been found to be unlawful and successfully challenged in court.8 And in December of 2024, the General Counsel of the Department of Health and Human Services (HHS) issued an Advisory Opinion stating that the HHS Secretary lacks authority to approve states’ attempts9 to impose reporting requirements for work, study, volunteering, or other activities as a condition of Medicaid eligibility or continued enrollment because they conflict with the core objective of Medicaid.10

Despite this, elected Republican officials and lawmakers want to impose work reporting requirements on individuals otherwise qualified for the Medicaid program.

Work reporting requirements are based on a false premise –Medicaid enrollees who can work, already work.

The idea that Medicaid enrollees need an incentive to work – Medicaid coverage – or should be punished if they don’t work – through loss of coverage – is based on the false narrative that Medicaid enrollees do not work. This is a distortion of reality predicated on over-invoked racialized and gendered stereotypes of beneficiaries that ignores the lived experiences of all low-income people across racial and gendered lines. In fact, most Medicaid enrollees who can work, do work. Data from the Center on Budget and Policy Priorities from 2023 confirms this: Nearly 65% of non-elderly Medicaid adults were working, with most working full-time.11 Most non-working adults reported incompatibilities with work, such as an illness or disability, caregiving responsibilities, or pursuing an education. These statistics demonstrate the truth of the many women and LGBTQ+ people who rely on Medicaid coverage: they are working individuals that need health care coverage otherwise not accessible to them and their families. Indeed, nearly half of working Medicaid enrollees are employed in industries with low rates of employer-sponsored health insurance, and a similar percentage are employed by employers not subject to penalties for not offering affordable health coverage.12 Moreover, consistent with Medicaid’s core objective, enrollees should be able to access health care coverage regardless of their immediate employment status.

So-called “work requirements” do not increase employment; they keep people from getting coverage.

Contrary to Republican lawmakers’ assertions, work reporting requirements do not increase employment. Rather, these requirements cut coverage and dissuade eligible individuals from applying for coverage with burdensome reporting and administrative requirements.

In Arkansas, a Medicaid work reporting requirement in effect from August to December 2018 stripped over 18,000 people of coverage, including working and otherwise eligible individuals.13 Many were unaware of the new reporting requirements until they were disenrolled and seeking care, and others encountered difficulties navigating the inadequate reporting website which was only available at certain times of the day.14 Arkansas’s reporting requirement caused anxiety, confusion, and coverage loss, but did not incentivize or increase employment.15

In Georgia, a work reporting requirement in effect since July 1, 2023, conditions Medicaid coverage on at least 80 hours of work or volunteer activities per month, including at the time of application. Despite more than 200,000 uninsured people potentially eligible for coverage and 110,000 people who initially expressed interest, only 6,50016 have been enrolled after more than a year.17 Nearly 1 in 5 people who completed applications were denied for insufficient or non-qualifying work hours.18 And in June 2024 alone, more than 40% of people who started applications were terminated from the application process for not reporting any work hours. There is no data to show an increase in employment because of this program. Rather, Georgia’s burdensome reporting requirements—a lengthy process throughout which individuals struggle to understand technical and bureaucratic language and face difficulties obtaining and uploading documents that verify their employment or education,19 deter otherwise eligible applicants. As a result, hundreds of thousands of low-income and working people remain unnecessarily uninsured, vulnerable to skipping necessary care and taking on medical debt.

Research shows that work reporting requirements in other programs do not help people find long-term employment.

Over the last 20 years, work reporting requirements have been implemented in various public benefits programs, yet these requirements have failed to move individuals and families out of poverty. In fact, many families were worse off after work reporting requirements were implemented. There is no reason to think implementing similar requirements in Medicaid would achieve success where others have not.

Temporary Assistance for Needy Families (TANF) program work reporting requirements are often used as a model for adding similar requirements to Medicaid.20 Yet, research found that:

  • TANF work reporting requirements made little difference in long-term employment rates. Regardless of whether individuals were subject to the requirements, at least 75% of TANF recipients worked by the fifth year of leaving the program.21
  • TANF work reporting requirements increased deep poverty.22 The share of families living in deep poverty—below half of the poverty line—increased in states with the requirements.
  • The large majority of individuals subject to work reporting requirements remained poor and worked in low-quality, low-wage jobs with high volatility.23

Research on Supplemental Nutrition Assistance Program (SNAP) “work requirements,” a misnomer for time limits on program eligibility dependent on work or training documentation, similarly indicates little success. SNAP time limits failed to increase employment and significantly decreased participation in SNAP.24 Other studies found that these requirements, on average, reduced income across all recipients and reduced benefits more than they increased people’s earnings.25

Just as work reporting requirements in other programs harmed people’s economic security, so too will conditioning Medicaid coverage on work reporting requirements fail to improve the economic security of Medicaid enrollees. So-called Medicaid “work requirements” will force individuals who cannot work or cannot meet the strict requirements to choose between risking their own health or family’s wellbeing by working or risking their health by going without health insurance and needed medical care. Without insurance coverage, individuals are more likely to experience declines in their health,26 making it even more difficult for them to find and retain employment. Uninsurance also increases the likelihood of medical debt and difficulty paying living expenses,27 exacerbating economic instability.

Women and LGBTQ+ people are especially likely to lose health care coverage under a Medicaid work reporting requirement.

With over 18 million women receiving coverage through Medicaid,29 the majority of Medicaid adult enrollees are women, and more than 6 in 10 of the nonelderly Medicaid enrollees who were not working in 2021 were women.30 LGBTQ+ individuals are also more likely than their non-LGBTQ+ counterparts to receive coverage through Medicaid.31

Work reporting requirements pose a greater risk to women and LGBTQ+ people, particularly women of color,32 transgender, and nonbinary33 individuals because these populations experience greater barriers to employment due to lack of support, discrimination, and harassment. These requirements also define work in ways that discount or ignore unpaid, caregiving work and disproportionately affect women’s and LGBTQ+ people’s ability to remain enrolled in Medicaid. Women are more likely than men to be the sole or primary caregivers of children and to be caregivers for aging parents and other family members. Women are also overrepresented in low-paid jobs that don’t accommodate caregiving responsibilities, including direct care workers who help provide essential health care to other people.34 Compared to non-LGBTQ+ counterparts, LGBTQ+ adults are also significantly more likely to provide caregiving for their friends and chosen family, and LGBTQ+ caregivers are more likely to be primary caregivers.35 Furthermore, the required number of work hours may be unattainable, even for Medicaid enrollees with regular work, if they are balancing other responsibilities like childcare, assisting family members, or if they are engaged in involuntary part-time work.36

Women37 and LGBTQ+ people38 also experience high rates of chronic conditions and disability that may make it more difficult to meet work reporting requirements. Studies of the implementation of TANF work reporting requirements found that TANF recipients who were sanctioned for not meeting these requirements have significantly higher rates of disability than those not sanctioned.

The very factors that make it more difficult for individuals to meet a work reporting requirement— caregiving responsibilities, lack of child care, disability, chronic conditions, or other limitations—make it more difficult for them to prove why they cannot meet a work requirement. And yet at the same time, low-income workers, who are more likely to be balancing part-time work and caregiving responsibilities, could face repeated and burdensome reporting requirements, increasing the chances of gaps in coverage and inability to access the care they need.39

Losing Medicaid coverage threatens the health and economic security of women and LGBTQ+ people.

All of these factors leave low-income women and LGBTQ+ people at particular risk of losing critical health coverage if work reporting requirements are imposed, threatening their health. Uninsured low-income women are more likely to go without care because of cost, are less likely to have a regular source of care and utilize preventive services at lower rates than low-income women with health insurance.40 Similarly, uninsured LGBTQ+ people are significantly less likely to have a regular health care provider or to have been seen for a wellness check-up in the past two years.41

A growing body of research has demonstrated how important Medicaid coverage is to enrollees’ access to care, overall health and mortality rates.42 And Medicaid coverage is particularly critical for women because, among all sources of coverage, Medicaid disproportionately covers the poorest and sickest population of women.43 Medicaid is also the primary source of coverage for adults living with HIV – disproportionately LGBTQ+ people – and transgender people with disabilities.44

At the same time, Medicaid has played an important role in advancing enrollees’ economic security. Medicaid coverage actually helps spur employment, because it can help women and LGBTQ+ people deal with the health problems that are a barrier to employment by providing access to preventive care, treatment for health problems before they become more serious, and assistance managing chronic conditions. After Ohio expanded Medicaid coverage under the Affordable Care Act, its Medicaid Department found that three-quarters of the adults who received coverage who were looking for work reported that Medicaid made it easier to do so, and more than half of those who were working said that Medicaid made it easier for them to keep their jobs.45 Similarly, in Michigan, more than half of those who received coverage who were looking for work reported that Medicaid made it easier to do so, and nearly seventy-percent of those who were working said that Medicaid made it easier for them to keep their jobs.46

Medicaid keeps women, families, and LGBTQ+ people from medical debt and bankruptcy.47 By providing health coverage that is not tied to employment, Medicaid allows women and LGBTQ+ people to seek positions that may offer higher wages or better opportunities, and it also has improved the economic security of future generations. Medicaid’s coverage of birth control allows women to determine whether and when to start a family, expanding their educational and career opportunities.48 Gender affirming care, covered by more than half of Medicaid programs, improves mental health49 and allows trans and non-binary individuals to engage more fully in educational and career opportunities. Imposing work reporting requirements in the Medicaid program would jeopardize these gains, putting the financial wellbeing of women, families, and LGBTQ+ people on the line.

We should not enact more millionaire tax breaks at the expense of the health and financial well-being of women, families, and LGBTQ+ people.

Medicaid work reporting requirements are ineffective, unjust, and based on false beliefs about low-income and working families. Yet Republican lawmakers continue to push these proposals because by stripping away Medicaid coverage from hundreds of thousands, if not millions, of eligible people through administrative barriers, they can help offset the enormous cost of even more tax breaks for the wealthiest and big corporations.

These so-called “work requirements” threaten the health and financial wellbeing of women, families, and LGBTQ+ people with low incomes. Billionaires don’t need any more tax cuts, certainly not at the expense of everyday families.

Find the official factsheet here.

 

1 For example, work reporting requirements in Arkansas, despite only being effect for five months, harmed thousands of Medicaid enrollees. See Madeline Guth & MaryBeth Musumeci, “An Overview of Medicaid Work Requirements: What Happened Under the Trump and Biden Administrations?,” Kaiser Family Found. (May 3, 2022), https://www.kff.org/medicaid/issue-brief/an-overview-of-medicaid-work-requirements-what-happened-under-the-trump-and-biden-administrations/.

2 Jennifer Tolbert et al., “Key Facts About the Uninsured Population,” Kaiser Family Found. (Dec. 18, 2024), https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/.

3 Gideon Lukens & Elizabeth Zhang, “Medicaid Work Requirements Could Put 36 Million People at Risk of Losing Health Coverage,” Ctr. on Budget & Pol’y Priorities (Jan. 16, 2025), https://www.cbpp.org/sites/default/files/1-16-25health.pdf; see also, U.S. Health & Hum. Servs., “Fact Sheet: Medicaid Work Requirements Would Jeopardize Health Coverage and Access to Care for 21 Million Americans” (2023), https://www.hhs.gov/sites/default/files/national-work-requirements-fact-sheet.pdf.

4 Nat’l Women’s Law Ctr., “NWLC Responds to Trump’s Authoritarian Move to Pause Federal Spending”, (Jan. 28, 2025), https://nwlc.org/press-release/nwlc-responds-to-trumps-authoritarian-move-to-pause-federal-spending/.

5 Ben Leonard et al., House GOP Puts Medicaid, ACA, Climate Measures on Chopping Block, POLITICO (Jan. 10, 2025), https://www.politico.com/news/2025/01/10/spending-cuts-house-gop-reconciliation-medicaid-00197541.

6 Nat’l Women’s Law Ctr., “National Snapshot: Poverty Among Women & Families in 2023,” (Dec. 11, 2024), https://nwlc.org/resource/national-snapshot-poverty-among-women-families-in-2023/.

7 42 U.S.C. §1396 et seq.

8 See Nat’l Women’s Law Ctr., “NWLC and Partners File Amicus Brief Opposing Medicaid Work Requirements, Emphasizing Harm to Women of Color – National Women’s Law Center,” (Feb. 25, 2021), https://nwlc.org/resource/nwlc-and-partners-file-amicus-brief-opposing-medicaid-work-requirements/.

9 States can apply to the Department of Health and Human Services (HHS) to waive requirements in the Medicaid statute (called a “waiver”) to allow the state to implement an experimental or demonstration project to help achieve Medicaid’s goals. Waivers are often undertaken through Section 1115 of the Social Security Act which allows for waivers of the requirements in 42 U.S.C. § 1396a. 42 U.S.C. § 1315.

10 Advisory Opinion 24-01 on Medicaid Section 1115 Demonstrations Imposing Work Requirements, (U.S. Health & Hum. Servs. Dec. 11, 2024) (Op. Gen. Couns), https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/advisory-opinion-24-01.pdf.

11 Gideon Lukens, supra note 3.

12 Madeline Guth et al., “Understanding the Intersection of Medicaid & Work: A Look at What the Data Say,” Kaiser Family Found. (Apr. 24, 2023), https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-work-a-look-at-what-the-data-say/.

13 Id.

14 Laura Harker, “Pain But No Gain: Arkansas’ Failed Medicaid Work-Reporting Requirements Should Not Be a Model,” Ctr. on Budget & Pol’y Priorities (Aug. 8, 2023), https://www.cbpp.org/research/health/pain-but-no-gain-arkansas-failed-medicaid-work-reporting-requirements-should-not-be; see also, MaryBeth Musumeci et al., “Medicaid Work Requirements in Arkansas: Experience and Perspectives of Enrollees,” Kaiser Family Found. (Dec. 18, 2018), https://www.kff.org/medicaid/issue-brief/medicaid-work-requirements-in-arkansas-experience-and-perspectives-of-enrollees/.

15 Laura Harker, supra note 14; see also, MaryBeth Musumeci et al., supra note 14.

16 Current Enrollment listed on Georgia Pathways Data Tracker (Jan. 2, 2025), https://www.georgiapathways.org/data-tracker.

17 Luara Harker, “Georgia’s Medicaid Experiment Is the Latest to Show Work Requirements Restrict Health Care Access,” Ctr. on Budget & Pol’y Priorities (Dec. 19, 2024), https://www.cbpp.org/blog/georgias-medicaid-experiment-is-the-latest-to-show-work-requirements-restrict-health-care.

18 Leah Chan, “Georgia’s Pathways to Coverage Program: The First Year in Review,” Georgia Budget & Pol’y Inst. (Oct. 29, 2024), https://gbpi.org/wp-content/uploads/2024/10/PathwaystoCoverage_PolicyBrief_2024103.pdf.

19 Code for America, Innovation Lab “Georgia Pathways to Coverage Journey Map,” (2024), https://gbpi.org/wp-content/uploads/2024/04/GPTC_JOURNEYMAP.pdf.

20 The TANF work requirements were a model for the Medicaid work requirements proposed in the AHCA. See Vann R. Newkirk II, “The Trouble with Medicaid Work Requirements,” THE ATLANTIC (Mar. 23, 2017), https://www.theatlantic.com/politics/archive/2017/03/why-work-requirements-in-medicaid-wont-work/520593/.

21 Ladonna Pavetti & Ali Zane, “TANF Cash Assistance Helps Families, But Program Is Not the Success Some Claim,” Ctr. on Budget & Pol’y Priorities (Aug. 2, 2021), https://www.cbpp.org/research/income-security/tanf-cash-assistance-helps-families-but-program-is-not-the-success-some; see also Ladonna Pavetti, “Work Requirements Don’t Cut Poverty, Evidence Shows,” Ctr. on Budget & Pol’y Priorities (Jun. 7, 2016), https://www.cbpp.org/research/test-work-requirements-dont-cut-poverty-evidence-shows.

22 Ladonna Pavetti & Ali Zane, supra note 21; see also Ladonna Pavetti, supra note 21.

23 Ladonna Pavetti & Ali Zane, supra note 21; see also Ladonna Pavetti, supra note 21.

24 “Work requirements” is a misnomer for time limits because a person’s willingness to work or conduct an active job search does not protect them against being cut off from SNAP. Under SNAP time limits, individuals ages 18 to 50 who are not students, pregnant, caring for a child or incapacitated person, and do not have a disability cannot receive SNAP for more than three months in a 36-month period if they cannot document sufficient work hours or participate in a work training program for at least 20 hours a week. See Food Rsch. & Action Ctr. & Nat’l Women’s Law Ctr., “SNAP Time Limits Harm Women LGBTQIA+ People, AND Families,” (Sep. 2023), https://frac.org/wp-content/uploads/NWLC-FRAC-SNAP-Time-Limits-Fact-Sheet.pdf.

25 Lauren Bauer & Chloe East, “A Primer on SNAP Work Requirements,” The Hamilton Project ( Oct. 2023), https://www.hamiltonproject.org/wp-content/uploads/2023/10/20231004_THP_SNAPWorkRequirements.pdf; Elaine Waxman & Heather Hahn, “Work Requirements Sound Good, but the Evidence Just Doesn’t Support Them,” URBAN WIRE (Oct. 26, 2021), https://www.urban.org/urban-wire/work-requirements-sound-good-evidence-just-doesnt-support-them.

26 Cong. Budget Office, “Work Requirements and Work Supports for Recipience of Means-Tested Benefits,” (June 2022), https://www.cbo.gov/system/files/2022-06/57702-Work-Requirements.pdf.

27 Jennifer Tolbert et al., supra note 2.

28 Id.

29 Enrollment data listed at Kaiser Family Foundation, Distribution of Adults Ages 19-64 with Medicaid by Sex, Timeframe: 2023, https://www.kff.org/medicaid/state-indicator/medicaid-distribution-adults-19-64-by-sex/?dataView=1&currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

30 Madeline Guth et al., “Understanding the Intersection of Medicaid & Work: A Look at What the Data Say,” App. Tbl., Kaiser Family Found. (Apr. 24, 2023), https://www.kff.org/report-section/understanding-the-intersection-of-medicaid-work-a-look-at-what-the-data-say-appendix/.

31 MACPAC, “Access in Brief: Experiences of Lesbian, Gay, Bisexual, and Transgender Medicaid Beneficiaries with Accessing Medical and Behavioral Health Care,” (June 2022), https://www.macpac.gov/wp-content/uploads/2022/06/Access-in-Brief-Experiences-in-Lesbian-Gay-Bisexual-and-Transgender-Medicaid-Beneficiaries-with-Accessing-Medical-and-Behavioral-Health-Care.pdf.

32 Jessica Shakespeare et al., “Racial Equity and Job Quality: Causes Behind Racial Disparities and Possibilities to Address Them,” Urban Inst. (Sep. 2021), https://www.urban.org/sites/default/files/publication/104761/racial-equity-and-job-quality.pdf.

33 Brad Sears et al., “LGBTQ People’s Experiences of Workplace Discrimination and Harassment,” Williams Inst. (Aug. 2022), https://williamsinstitute.law.ucla.edu/publications/lgbt-workplace-discrimination/.

34 Nat’l Women’s Law Ctr., “Hard Work Is Not Enough: Women In Low-Paid Jobs,” (Jul. 20, 2023), https://nwlc.org/resource/when-hard-work-is-not-enough-women-in-low-paid-jobs/.

35 Liz Gipson et al., “LGBTQ+ Caregivers: Challenges, Policy Needs, and Opportunities,” Ctr. Health Care Strategies (Nov. 2022), https://www.chcs.org/media/LGBTQ-Caregivers-Challenges-Policy-Needs-and-Opportunities_FINAL.pdf; Nat’l Ctr. for Chronic Disease Prevention, “Caregiving Among Lesbian, Gay, Bisexual, Transgender (LGBT) Adults [2015-2018],” (Jun. 1, 2020), https://stacks.cdc.gov/view/cdc/117382.

36 Nat’l Women’s Law Ctr., “Five Things You Should Know About Part-Time Workers,” (Feb. 27, 2020), https://nwlc.org/five-things-you-should-know-about-part-time-workers/.

37 Nat’l Acads. Sci, Eng’g, & Med., “Advancing Research on Chronic Conditions in Women,” (Sep. 25, 2024), https://www.ncbi.nlm.nih.gov/books/NBK604853/.

38 Lindsey Dawson et al., “LGBT+ People’s Health Status and Access to Care,” Kaiser Family Found. (Jun. 30, 2023), https://www.kff.org/report-section/lgbt-peoples-health-status-and-access-to-care-issue-brief/.

39 Jennifer Tolbert et al., supra note 2.

40 Kaiser Family Found., “Women’s Health Insurance Coverage,” (Dec. 12, 2024), https://www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage/.

41 Lindsey Dawson et al., supra note 38.

42 Madeline Guth & Meghana Ammula, “Building on the Evidence Base: Studies on the Effects of Medicaid Expansion, February 2020 to March 2021,” Kaiser Family Found. (May 6, 2021), https://www.kff.org/report-section/building-on-the-evidence-base-studies-on-the-effects-of-medicaid-expansion-february-2020-to-march-2021-report/.

43 Kaiser Family Found., supra note 40.

44 MACPAC, supra note 31.

45 Ctr. on Budget & Pol’y Priorities, “The Far-Reaching Benefits of the Affordable Care Act’s Medicaid Expansion,” (Oct. 21, 2020), https://www.cbpp.org/research/health/chart-book-the-far-reaching-benefits-of-the-affordable-care-acts-medicaid-expansion#4.

46 Id.

47 See generally, Nat’l Women’s Law Ctr., “Medicaid at 50: Celebrating Medicaid’s Contributions to Women’s Economic Security,” (July 2015), http://nwlc.org/wp-content/uploads/2015/08/final_nwlc_medicaid50th_whitepaper_3.pdf.

48 Adam Sonfield et al., “The Social and Economic Benefits of Women’s Ability To Determine Whether and When to Have Children,” Guttmacher Inst. (Mar. 2013), https://www.guttmacher.org/sites/default/files/pdfs/pubs/social-economic-benefits.pdf.

49 Anthony Almazan & Alex Keuroghlian, “Association Between Gender-Affirming Surgeries and Mental Health Outcomes,” 7 JAMA SURGERY 611 (Apr. 28, 2021), doi:10.1001/jamasurg.2021.0952.