Medicaid Work Requirements: Eight Disconnects

Work requirements appear to be ineffective.

At present, 37 states and the District of Columbia have passed Medicaid expansion. All 50 states may not agree on the concept of expansion, yet they share one point of consensus. The reality of high numbers of enrollees dealing with complex health and behavioral health needs, exacerbated by issues associated with the various social determinants of health (SDoH), plus insufficient resources, have all the states concerned about being able to afford their Medicaid plans, and ultimately being able to care for their residents.

The proposed resolution was for the states to impose Medicaid work requirements. However, new evidence from Harvard’s TH Chan School of Public Health and The Urban Institute reveals just how ineffective the requirement has been.

Disconnects with Reality

Sixteen states have imposed Medicaid work requirements, with another six having legislation pending. The National Academy for State Health Policy website provides a table showing all the states impacted by Medicaid expansion and work requirements, qualifying activities, population groups, exemptions, and non-compliance penalties. Employment minimums were also set as a condition of enrollment, ranging from 20 hours weekly, to 80, or even 100 hours monthly. Varied exemptions were defined for a range of diverse populations across the states, including but not limited to:

  • Full-time high school, trade school, college or graduate students,
  • Those persons who are pregnant, disabled, or medically frail
  • Caregivers for a disabled child or adult
  • Foster youth up to age 26
  • Children under the age of 19
  • Individuals residing in an institution
  • Victims of domestic violence or homeless individuals
  • Those receiving unemployment benefits
  • Those in substance abuse treatment programs

Qualifying activities were defined across employment and community engagement.

Disconnect No. 1: The studies identified barriers to accessing substance use treatment for Medicaid recipients, such as the following:

  • Extensive waiting lists of 4-8 months due to provider and program deserts
  • Denial of appointments or program admission based on Medicaid coverage alone

We won’t cloud the issue with logic, but what good is providing a qualifier that can’t be met?

Disconnect No. 2: Most targeted persons were already employed. The Urban Institute specifically surveyed 1,180 adult Medicaid enrollees about employment obstacles and found that:

  • 60 percent worked in the past year
  • 19 percent worked 20 hours a week “most” weeks 

This particular issue has played out across a number of the states, including the winner of my “Disconnect Award,” Arkansas. 

As the first state to pass work requirements in 2018, Arkansas’s action has resulted in more uninsured persons than in any other state. 18,000 people fell off the Medicaid roster as a direct result of the work requirement implementation.  

Disconnects Nos. 3-7:

  • The requirements did nothing to promote employment, offering few to any employment support or training programs.
  • Enrollees had to use an online portal for reporting, despite 20 percent lacking Internet access and another 20 percent lacking fast broadband.
  • The portal was unavailable after 9 p.m., a problem since many persons worked lengthy shifts, or multiple jobs.
  • One-third of the individuals subject to the work requirements never heard of them, with 50 percent unsure if the requirements even applied to them.
  • Over 95 percent of the residents subject to the work requirements already met them or were eligible for the exemptions in their state.

Need I say more about clouding the issue with logic?

Disconnect No. 8: The quantitative data provided by the initial seminal studies on Medicaid work requirements validates that the actions are out of sync with reality.

What is the answer?  

States must know what SDoH are predominant to leverage appropriate programming for their communities. To get a sense of our stakeholders’ thoughts on the matter, this week’s Monitor Mondays Listener Survey (sponsored by the American College of Physician Advisors) asked that very question. The results appear below:

Survey: Which Social Determinant Would You Be Most Likely to Seek Reimbursement For?

Survey Question

Total Responses

Unique Respondents

Survey Answer Options

Survey Answer Selections (%)

Which Social Determinant Would You Be Most Likely to Seek Reimbursement For?





Food Insecurity


Social isolation (e.g. no family/support system/caregiver)




Adult abuse, neglect, or exploitation



Perhaps the impetus for expanded community-based programming and push for reimbursement through expanded ICD-10-CM Z codes will serve as a more viable alternative than work requirements.


Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP

Ellen Fink-Samnick is an award-winning healthcare industry expert. She is the esteemed author of books, articles, white papers, and knowledge products. A subject matter expert on the Social Determinants of Health, her latest books, The Essential Guide to Interprofessional Ethics for Healthcare Case Management and Social Determinants of Health: Case Management’s Next Frontier (with foreword by Dr. Ronald Hirsch), are published through HCPro. She is a panelist on Monitor Mondays, frequent contributor to Talk Ten Tuesdays, and member of the RACmonitor Editorial Board.

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