By James Coleman
Recently filed Senate Bill 387 would implement work or community service requirements for able-bodied adults enrolled in North Carolina’s Medicaid program. Medicaid work requirements were first introduced as an option for states by the federal government in 2018. Thus far only states that have expanded Medicaid have had work requirements approved by the Centers for Medicare and Medicaid Services.
Since the passage of the Affordable Care Act in 2010, 36 states and Washington, D.C. have expanded Medicaid coverage to low-income, working-age adults who would not have qualified for the program under previous Medicaid eligibility requirements. The implementation and administration of work requirements varies by state, but the approaches are similar in requiring adults who receive Medicaid coverage to report a certain number of hours of employment or job search/job training activities per week or month to keep their Medicaid eligibility. Generally, pregnant women, the disabled, and those with children are exempt from these requirements.1
Employment verification is not a federal requirement for Medicaid eligibility, so in order for states to include work requirements, they must gain approval from the Centers for Medicaid Services (CMS) through section 1115 Medicaid demonstration waivers.2 As of March 2019, eight state work requirements waivers have been approved, with seven currently being considered by CMS.3 So far, 3 out of the 8 approved states have implemented their work requirements : Arkansas (June 2018), Indiana (January 2019), and New Hampshire (March 2019).
Work requirements are controversial, to say the least. Opponents claim that the implementation of work requirements will lead many to lose their Medicaid coverage, that they are unnecessary because most Medicaid recipients already work, and that their true purpose is to kick people off of Medicaid as a cost-cutting measure.4,5 Proponents argue that requiring employment as a condition for Medicaid coverage is for the benefit of able-bodied adult Medicaid recipients, encouraging them to enter the workforce, to escape poverty, and to get off government assistance.1,6
With the rollout of work requirements across the nation only in its infancy, there is still vigorous debate about their legality. While other federal benefits programs, such as SNAP (Supplemental Nutrition Assistance Program) and TANF (Temporary Assistance for Needy Families) include the option for work requirements in their federal statutes, Medicaid statutes do not. Because the option for work requirements was introduced by the current administration rather than through Congressional changes to the Medicaid statutes, the legality of such requirements is being contested in states where they have been implemented. On March 27, 2019, a federal judge blocked Medicaid work requirements in Arkansas and Kentucky. New Hampshire’s Medicaid work requirement policy is also being legally challenged in the federal courts.9
As the North Carolina General Assembly considers Medicaid work requirements, it is important to monitor these legal challenges and the experiences of states that have implemented work requirements.