Medicaid work-requirements are great, but states need flexibility to make them work

The Hill

30-04-2025

I was the first governor to implement work requirements on the working-age population that was on Medicaid. So I feel I have some standing to offer observations on what happened in Arkansas — a few lessons learned and recommendations to Congress as it considers a federal mandate on states to impose work and work-related activities as a condition of Medicaid eligibility.
For a number of reasons, I am firmly in favor of work requirements for able-bodied working-age adults on Medicaid. Most importantly, work meets the objectives of Medicaid as an anti-poverty program. Work is a vital part of our human dignity, and participation is a fair way to honor the social contract between working-age adults on public assistance and their neighbors and communities.
The first question about work requirements is the most important one: What is the goal?
If the answer is to simply lower federal spending, then it will be easy to construct rigid rules that result in savings due to noncompliance and reducing the number of people receiving benefits.
But if the goal is to actually help individuals and families escape poverty and achieve long-term self-sufficiency — which I believe should be the answer — then the assignment is much harder. This goal requires some flexibility for states to design programs that match their unique differences.
Arkansas has one of the highest poverty levels among the states at 16 percent. However, the work opportunities in Benton County, Ark., home to Walmart and other large corporations, are very different from those in the Delta counties. Benton County has a higher median income for both households and individuals than the national income levels. In contrast, Phillips County, in the Mississippi Delta, has a poverty rate of 33 percent. The approaches to help people cross from poverty to independence cannot be the same between these two counties.
The federal government created the so-called 'poverty trap' in which a person who goes to work loses more in in public benefits than he or she gains in income. This discourages work and results in more dependence.
That is the compelling reason we need a work requirement that also supports increased training opportunities for the able-bodied. States need flexibility in devising work requirements that actually help people move up the employment ladder.
One of the lessons learned in Arkansas was that relying on technology and data-matching for implementing a work requirement is insufficient. The results were poor. The human element is needed to make sure people are given every opportunity to have both health care and work or worker training.
A quick look at the data shows the diversity of the Medicaid-eligible population. Many in the youngest age group move from the children's coverage under Medicaid into Affordable Care Act coverage simply because they have a birthday. They have little or no income because they have chosen to extend their education or have not been fully assimilated into the workforce. Many of these young adults will find their own way off Medicaid within 12 months without any further intervention.
It is quite a different story for a 55 year-old single adult with a significant work history who ended up on Medicaid due to a major illness or accident. A single mother with prior work experience and at least some post-high school education may be one of the most interested and motivated individuals to return to work if proper support is available.
The differences in the demographics serve as a lesson for Congress to resist the temptation to take a cookie-cutter approach. Congress must allow states sufficient latitude to tailor interventions to different populations. Blanket exemptions will result in missed opportunities, but so will limitations on ways to demonstrate compliance with work requirements.
It has been widely reported that about 18,000 Arkansans lost their Medicaid eligibility due to noncompliance with work requirements. There has been little attention to the fact that 6,000 of these returned to Medicaid within 12 months. What happened to the rest? Although Arkansas didn't have the opportunity to study what happened to those who did not return, the answer is likely similar to what occurred nationally after the pandemic-era Public Health Emergency ended ('the unwind'). That is when the states were once again allowed to review Medicaid eligibility.
As the unwind was concluding in late 2024, Medicaid and CHIP enrollment returned to 79.4 million and Marketplace coverage increased to 23.5 million. In other words, people moved from public coverage to private coverage because work opportunities increased. That should be the explicit goal of work requirements as well, and it must be the real measure of success.
Congress has a unique opportunity to allow states to have a work requirement under Medicaid and at the same time allow the states to innovate and try different approaches that function best for those who value the dignity of work.