Expanded Medicaid, SNAP work requirement bill approved by Senate subcommittee
Sen. Mike Bousselot, R-Ankeny, spoke March 20, 2025 on legislation directing the Iowa Department of Health and Human Services to seek federal waivers to implement work requirements for the state's expanded Medicaid program and other benefits like SNAP. (Photo by Robin Opsahl/Iowa Capital Dispatch)
Legislation setting work requirements to receive Medicaid and SNAP benefits was approved by a Senate appropriations subcommittee Thursday.
The bill, Senate File 599, directs the Iowa Department of Health and Human Services to seek a waiver from the federal government to institute work requirements for the Iowa Health and Wellness Plan (IHAWP), the state's Medicaid expansion program. The bill adds work requirements for other public assistance programs as well, including for food aid through the Supplemental Nutrition Assistance Program (SNAP).
The work requirements would apply to Iowans between age 19 and 65, with exceptions listed to the work requirements, including people with disabilities, parents of children under age 6, people with a high-risk pregnancy and those in substance abuse treatment programs for a period of up to six months.
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While an earlier version of the bill set a requirement for Iowans to work or volunteer 20 hours a week to maintain IHAWP membership, language in the current legislation does not specify how many hours would be necessary to maintain benefits.
Several speakers said denying Iowans assistance who do not fit into these exceptions would lead to much higher overall costs for Iowa's health care system, by not giving consideration to people like parents of children with disabilities, who are unable to work while caring for their child, or for people who are not disabled but still require access to their prescription medicine in order to avoid being hospitalized and to maintain a job.
Leslie Carpenter with Iowa Mental Health Advocacy gave a fiscal estimates for the cost of 100 people who would need to make a hospital emergency department visit if they cannot access their medication after being removed from Medicaid coverage. The U.S. Department of Health and Human Services estimated the average cost of an emergency department visit to be $1,506, she said, which means a there would be a cost of roughly $150,000 for 100 patients being hospitalized for a day and $1,316,000 if they were hospitalized for a week.
'I suspect that my estimates of having only 100 people who are severely sick being at risk for having their Medicaid insurance lost is actually quite low,' Carpenter said. 'If those numbers are actually higher, you can imagine the fiscal impact on the taxpayers.'
Others called for Iowa legislators to look at other states, including Georgia, which have tried to implement Medicaid work requirements as proof that the policy does not work. Anne Discher with Common Good Iowa, a progressive nonprofit, also cautioned against Iowa lawmakers moving on work requirements when federal action is expected on the subject.
'It feels a little bit like we're rushing forward on this bill at a point where we know at the federal level, Republicans are very interested in making massive changes to SNAP and to Medicaid, and the area where there seems to be agreement at the federal level is on something in the vicinity of reporting requirements,' Discher said. 'We certainly oppose those at the federal level. However, the worst case scenario, the worst of both worlds would be for Iowa to rush ahead, the feds do something different, and then we have to come back and clean it up.'
The bill proposes suspending Iowa's expanded Medicaid program if work requirements are not implemented, and would resume it if the work rules take effect. That could at least temporarily halt IHAWP, which provides health coverage to adults age 19 through 65 who have an income at or below 133% of the federal poverty level — roughly $20,030 for a single adult and $27,186 for a married couple. According to data compiled by the Legislative Services Agency, there were 179,918 Iowa adults on IHAWP in fiscal year 2025.
At the subcommittee meeting, multiple advocates criticized the bill for tying IHAWP coverage to receiving federal approval. MaryNelle Trefz with Iowa ACEs 360, an advocacy group focused on trauma recovery and support, said this provision will create financial hardships for Iowa's economy by requiring federal approval for Iowa's expanded Medicaid program to continue to exist.
'If those requirements aren't approved now or in the future, Iowa would be forced to walk away from expansion entirely, jeopardizing coverage for thousands, increasing costs for hospitals and businesses, and worsening our workforce shortage,' Trefz said.
Sen. Mark Costello, R-Imogene, said there were 'misunderstandings' about the IHAWP trigger provisions, saying he received letters from constituents who believed other Medicaid and benefit programs would be impacted if the federal government does not approve Iowa's request to implement reporting requirements.
'That is, you know, a group that is already in a higher income or (a part of the) expanded population there, that we would hope some of them would be able to get insurance through the exchange or whatever,' Costello said.
Sen. Mike Bousselot, R-Ankeny, said he has been involved in state government since former Gov. Terry Branstad signed IHAWP into law in 2013. He said adding work requirements to the program 'is common sense and is in line with why and how the bill passed at the very beginning.'
'The safety net is intended to be just that, a safety net that bounces people back up, not a poverty trap that has folks that are consistently sticking and staying and have no incentive to get off of those taxpayer-funded services,' Bousselot said. 'The work and job training requirements that are found in this bill, and the goal to align those, are in line with the idea that job and work requirements have existed for folks that are disabled on Medicaid for decades, have existed for other social services that taxpayers provide.'
While Iowa lawmakers are pursuing legislative action to implement work requirements, Gov. Kim Reynolds also said during her Condition of the State address in January she plans to apply for a federal waiver to implement Medicaid work requirements.
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For proponents, the ideas behind the work requirement are simple: Crack down on fraud and stand on the principle that taxpayer-provided health coverage isn't for those who can work but aren't. The measure includes exceptions for those who are under 19 or over 64, those with disabilities, pregnant women, main caregivers for young children, people recently released from prisons or jails — or during certain emergencies. It would apply only to adults who receive Medicaid through expansions that 40 states chose to undertake as part of the 2010 health insurance overhaul. Many details of how the changes would work would be developed later, leaving several unknowns and causing anxiety among recipients who worry that their illnesses might not be enough to exempt them. Advocates and sick and disabled enrollees worry — based largely on their past experience — that even those who might be exempted from work requirements under the law could still lose benefits because of increased or hard-to-meet paperwork mandates. Benefits can be difficult to navigate even without a work requirement Strickland, a 44-year-old former server, cook and construction worker who lives in Fairmont, North Carolina, said she could not afford to go to a doctor for years because she wasn't able to work. She finally received a letter this month saying she would receive Medicaid coverage, she said. 'It's already kind of tough to get on Medicaid,' said Strickland, who has lived in a tent and times and subsisted on nonperishable food thrown out by stores. 'If they make it harder to get on, they're not going to be helping.' Steve Furman is concerned that his 43-year-old son, who has autism, could lose coverage. The bill the House adopted would require Medicaid enrollees to show that they work, volunteer or go to school at least 80 hours a month to continue to qualify. A disability exception would likely apply to Furman's son, who previously worked in an eyeglasses plant in Illinois for 15 years despite behavioral issues that may have gotten him fired elsewhere. Furman said government bureaucracies are already impossible for his son to navigate, even with help. It took him a year to help get his son onto Arizona's Medicaid system when they moved to Scottsdale in 2022, and it took time to set up food benefits. But he and his wife, who are retired, say they don't have the means to support his son fully. 'Should I expect the government to take care of him?' he asked. 'I don't know, but I do expect them to have humanity.' There's broad reliance on Medicaid for health coverage About 71 million adults are enrolled in Medicaid now. And most of them — around 92% — are working, caregiving, attending school or disabled. Earlier estimates of the budget bill from the Congressional Budget Office found that about 5 million people stand to lose coverage. A KFF tracking poll conducted in May found that the enrollees come from across the political spectrum. About one-fourth are Republicans; roughly one-third are Democrats. The poll found that about 7 in 10 adults are worried that federal spending reductions on Medicaid will lead to more uninsured people and would strain health care providers in their area. About half said they were worried reductions would hurt the ability of them or their family to get and pay for health care. Amaya Diana, an analyst at KFF, points to work requirements launched in Arkansas and Georgia as keeping people off Medicaid without increasing employment. Amber Bellazaire, a policy analyst at the Michigan League for Public Policy, said the process to verify that Medicaid enrollees meet the work requirements could be a key reason people would be denied or lose eligibility. 'Massive coverage losses just due to an administrative burden rather than ineligibility is a significant concern,' she said. One KFF poll respondent, Virginia Bell, a retiree in Starkville, Mississippi, said she's seen sick family members struggle to get onto Medicaid, including one who died recently without coverage. She said she doesn't mind a work requirement for those who are able — but worries about how that would be sorted out. 'It's kind of hard to determine who needs it and who doesn't need it,' she said. Some people don't if they might lose coverage with a work requirement Lexy Mealing, 54 of Westbury, New York, who was first diagnosed with breast cancer in 2021 and underwent a double mastectomy and reconstruction surgeries, said she fears she may lose the medical benefits she has come to rely on, though people with 'serious or complex' medical conditions could be granted exceptions. She now works about 15 hours a week in 'gig' jobs but isn't sure she can work more as she deals with the physical and mental toll of the cancer. Mealing, who used to work as a medical receptionist in a pediatric neurosurgeon's office before her diagnosis and now volunteers for the American Cancer Society, went on Medicaid after going on short-term disability. 'I can't even imagine going through treatments right now and surgeries and the uncertainty of just not being able to work and not have health insurance,' she said. Felix White, who has Type I diabetes, first qualified for Medicaid after losing his job as a computer programmer several years ago. The Oreland, Pennsylvania, man has been looking for a job, but finds that at 61, it's hard to land one. Medicaid, meanwhile, pays for a continuous glucose monitor and insulin and funded foot surgeries last year, including one that kept him in the hospital for 12 days. 'There's no way I could have afforded that,' he said. 'I would have lost my foot and probably died.' ___ Associated Press writer Susan Haigh in Hartford, Connecticut contributed to this article.
