Medicaid Work Requirements: What They Are and Where They've Been Tried

What Medicaid Work Requirements Actually Mean

When people refer to "Medicaid work requirements," they're describing a policy condition that would require certain Medicaid enrollees to demonstrate participation in work or work-related activities — such as job training, volunteering, or job searching — in order to maintain their health coverage. If an enrollee fails to meet the monthly threshold, their Medicaid benefits would be suspended or terminated until they demonstrate compliance.

This is distinct from how Medicaid has traditionally operated. Standard Medicaid eligibility is based on income, household size, age, disability status, and other factors. Employment status is not, on its own, a disqualifying or qualifying factor. A low-income adult who is unemployed can still qualify for Medicaid in expansion states, provided their income falls below the applicable threshold. See our full explanation of Medicaid eligibility for a breakdown of the standard qualification rules.

Work requirements represent a significant philosophical departure from that baseline. Proponents argue they promote self-sufficiency and incentivize workforce participation. Critics argue they create bureaucratic barriers that cause eligible people to lose coverage — not because they don't work, but because they can't navigate the reporting requirements.

It's important to understand that these policies do not change who is financially eligible for Medicaid. They add a new, behavioral layer on top of existing income and categorical rules. Someone who meets every standard Medicaid income test could still lose coverage if they fail to log their work hours through the state's reporting portal.

The Section 1115 Waiver: How States Get Permission

Federal Medicaid law, as written in the Social Security Act, does not include work requirements. States cannot simply add them on their own. To pursue a work requirement, a state must apply for a Section 1115 demonstration waiver — a formal request to the federal Centers for Medicare & Medicaid Services (CMS) to test an experimental policy that departs from standard Medicaid rules.

The waiver process involves several steps:

1. State application: The state submits a detailed proposal to CMS describing the policy, the target population, expected outcomes, and exemption categories.
2. Public comment period: CMS opens a period for public comment, typically 30 days, before making a decision.
3. Federal approval or denial: CMS evaluates the proposal and either approves, modifies, or denies it based on whether it advances the objectives of the Medicaid program.
4. Implementation: If approved, the state can begin implementing the requirement, usually subject to reporting conditions and periodic review.

The phrase "advances the objectives of the Medicaid program" has become central to the legal battles over work requirements. Federal courts have repeatedly held that a waiver which causes significant coverage losses cannot be said to advance a program whose core purpose is providing health coverage to low-income individuals.

Whether CMS approves or denies these waivers has varied sharply by administration. The Trump administration (2017–2021) approved work requirement waivers for multiple states. The Biden administration (2021–2025) reversed those approvals. The second Trump administration has signaled openness to approving them again. This political back-and-forth is one reason the work requirement landscape is so difficult to track.

A Timeline of State Attempts and Court Decisions

Understanding the history of work requirements requires tracking which states tried them, what happened, and why. Here is a summary of the most significant developments:

Arkansas (2018–2019)

Arkansas became the first and only state to fully implement a Medicaid work requirement under a program called Arkansas Works. Enrollees were required to report 80 hours per month of qualifying activities. Within months, approximately 18,000 people lost Medicaid coverage. A federal judge blocked the program in 2019, ruling that CMS had failed to consider the coverage losses in its approval decision. The Eighth Circuit and later the Supreme Court left that ruling largely intact.

Kentucky

Kentucky received approval for a work requirement in 2018 but was blocked by federal courts before implementation. The D.C. Circuit Court of Appeals ruled that CMS failed to adequately consider the impact on coverage when approving the waiver. The Biden administration withdrew the state's waiver in 2021.

New Hampshire and Michigan

Both states received approval and enacted enabling legislation, but implementation was paused or reversed following court rulings and subsequent federal waiver withdrawals under the Biden administration.

Georgia (2023–present)

Georgia launched a limited work requirement program called Pathways to Coverage in 2023 — notable because Georgia has not expanded Medicaid under the ACA, making Pathways a narrow coverage option for a specific population. As of 2024, enrollment in Pathways remained extremely low, with fewer than 4,000 enrollees in its first year, well below projections. Legal challenges to Pathways continued through 2024.

“The evidence from Arkansas is unambiguous: the state's work reporting requirement caused thousands of people to lose Medicaid coverage, and there is no evidence it moved a single person into employment who wasn't already working.”

— Benjamin Sommers, Professor of Health Policy and Economics, Harvard T.H. Chan School of Public Health

For a broader picture of how Medicaid rules differ across state lines — including which states have expanded Medicaid and which haven't — see our guide on why Medicaid eligibility varies so dramatically by state.

Who Is Typically Exempted — and Why It Matters

Even the most aggressive work requirement proposals have included exemptions for certain populations. Understanding who is exempted is critical, because it reveals both the intended scope of the policy and the practical challenges of implementation.

Common exemption categories include:

• Children — generally those under 18 or 19
• Pregnant women — typically for the duration of pregnancy and a postpartum period
• Adults with a documented disability — often defined as receiving SSI or SSDI, or having a verified medical condition
• Primary caregivers of young children (often under age 6) or of incapacitated adults
• Full-time students
• People in substance use disorder treatment
• Medically frail individuals, as verified by a health assessment

These exemptions are important for a key reason: research consistently shows that the vast majority of working-age, non-disabled Medicaid enrollees who are not already working face serious barriers — such as caregiving responsibilities, health conditions, or limited job availability — that make work requirements difficult to comply with, not because of a lack of desire to work.

The exemption process itself can be a source of coverage loss. Studies of the Arkansas program found that many people who were technically exempt — for example, because they were students or caregivers — lost coverage anyway because they didn't know they needed to report their exempt status through the state's online portal. The reporting system, not the substantive requirement, was the practical barrier.

This is why critics argue that work requirements function less as a work incentive and more as an administrative hurdle that weeds out eligible people who struggle with paperwork, internet access, or navigating state systems. To understand how states verify eligibility information more broadly, see our article on how Medicaid eligibility verification works.

The Legal Arguments For and Against

The legal battle over work requirements has played out primarily in federal district and appellate courts, with the central question being: does a Medicaid work requirement waiver lawfully advance the objectives of the Medicaid program?

Arguments in favor (from states and supportive administrations)

• Section 1115 gives the Secretary of Health and Human Services broad authority to approve experimental policies that further program objectives, and promoting self-sufficiency is a legitimate objective.
• Work requirements are modeled on similar conditions in SNAP (food stamps) and TANF (welfare), where they have statutory support.
• Encouraging employment may ultimately improve health outcomes, since employment is associated with better health and access to employer-sponsored insurance.

Arguments against (from courts and advocacy groups)

• The primary objective of Medicaid is to furnish medical assistance to low-income individuals. A waiver that causes thousands to lose coverage cannot be said to advance that objective.
• CMS approval decisions were "arbitrary and capricious" under the Administrative Procedure Act because they failed to meaningfully analyze coverage loss data.
• Most people who lose coverage under work requirements were already working, already exempt, or lost coverage due to reporting failures — not because they refused to work.

The Supreme Court has not issued a definitive ruling on the merits of work requirements. The most significant Supreme Court involvement came in 2022 in Becerra v. Gresham, when the Court dismissed a challenge to the Biden administration's waiver withdrawals as moot, leaving the underlying legal questions unresolved.

Current Status and What to Watch For

The work requirement landscape as of 2024–2025 is once again in flux. The second Trump administration has taken steps to encourage states to reapply for work requirement waivers, signaling federal openness to approving them. Several states — including Georgia, Indiana, and others — have either maintained pending waiver applications or filed new ones.

Georgia's Pathways program remains the only active example of a work requirement attached to any form of Medicaid coverage in the country, though its reach is limited to a narrow, non-expansion population. Its performance — particularly its low enrollment numbers — is being closely watched as evidence for both sides of the debate.

For consumers, the practical guidance is straightforward: work requirements do not currently affect most Medicaid enrollees in most states. If you live in a state that has or is pursuing a work requirement, monitor communications from your state Medicaid agency carefully. If a requirement is implemented, you would typically receive advance notice and instructions on how to report your qualifying activities or your exempt status.

Income limits remain the primary determinant of Medicaid eligibility. If you want to understand where your income falls relative to your state's thresholds, our state-specific Medicaid income limit reference provides detailed breakdowns by enrollee category. And if you're still getting oriented with how Medicaid eligibility works from the ground up, our guide to who qualifies for Medicaid is the right starting point.