Health Policy$ense

Safeguards Needed in Medicaid Work Requirements

Schmidt and Hoffman propose protections

In a push to encourage “personal responsibility,” the Centers for Medicare and Medicaid Services (CMS) has approved work requirements as a condition for receiving Medicaid benefits in four states - Kentucky, Indiana, Arkansas, and most recently New Hampshire, with applications from other states pending. In a new JAMA Viewpoint, Harald Schmidt and Allison Hoffman review the implications and ethics of Medicaid work requirements and other personal responsibility policies. They propose safeguards CMS should consider to minimize risk and protect beneficiaries’ health.


Allison Hoffman, JD, Professor of Law, and Harald Schmidt, PhD, MA, Assistant Professor of Medical Ethics & Health Policy

Under the Trump Administration, CMS has encouraged the inclusion of work requirements in Section 1115 waivers, which permit states to test and evaluate innovations in Medicaid that do not meet federal program rules. While work requirements have received the most attention, other personal responsibility policies CMS has encouraged include tying benefits to confirming eligibility annually, paying premiums on time, and meeting wellness program criteria. Prior demonstrations of these policies, however, have shown mixed results, raising questions about their ethics and effectiveness.

Although CMS exempts certain groups from work requirements, Schmidt and Hoffman note that non-exempt beneficiaries face a host of health problems and limitations that may keep them from meeting the requirements. For example, 28 percent of nonelderly adults (188,000 individuals) in Kentucky are not exempt and do not already work; of those, 41 percent have one or more serious health conditions, 18 percent have serious difficulties running errands, and 12 percent have no access to a vehicle.

Schmidt and Hoffman argue that work requirements and other personal responsibility demonstrations that jeopardize access to Medicaid represent research involving vulnerable populations. As such, these demonstrations should be paired with protections similar to those under the Common Rule governing research. They propose five initial safeguards CMS can implement:

  1. Continuously evaluate the feasibility of beneficiaries’ ability to meet new conditions; and offer guidance to ensure penalties are reasonable relative to the infraction.
  2. Identify high-risk subgroups and provide them proactive caseworker support, or exempt them altogether.
  3. Allow physicians to request exemptions to continue providing critical medical care for beneficiaries who fail to meet requirements, to avoid patients shifting to the ED for their health care needs.
  4. Provide guidance on what level of harm triggers program adjustment or termination. States should monitor the long term health effects of delayed or absent care as a result of not being able to meet requirements.
  5. Ensure procedural openness and transparency. Similar to clinical trials policy, waiver applications and evaluations should be publicly accessible in a central location to facilitate input from key stakeholders and to reduce the chances of poor study designs, faulty evaluations, and undisclosed harms.

All of the approved waivers have come from states that expanded Medicaid under the Affordable Care Act to include individuals with incomes below 138% of federal poverty level (FPL). However, some non-expansion states have signaled an interest in work requirements as well (including Kansas, Maine, Mississippi, Utah, Wisconsin, and most recently Oklahoma). In non-expansion states, beneficiaries can face a “subsidy cliff” in which their income disqualifies them for Medicaid, but remains below the federal threshold for subsidies on the health insurance marketplaces (100% FPL). In effect, people could work themselves out of affordable coverage.

During a roundtable with reporters, CMS Administrator Seema Verma signaled a cautious approach to approving work requirements in states that haven’t expanded Medicaid, expressing worry that some beneficiaries would lose coverage without alternatives. She suggested these programs may need to be structured differently from those the agency has approved to date.

We asked Schmidt and Hoffman for their take on Verma’s comments, and whether there is a difference in considering work requirements for the expansion vs. non-expansion population. They said:

“The expansion population is vulnerable in many of the same ways as the non-expansion population. We believe that CMS has not put sufficient protections in place for this population with the unprecedented green lighting of work requirements in Medicaid.”

If work requirement policies survive legal challenges, states should implement them with “great care, and unambiguously prioritize protecting health over political goals,” say Schmidt and Hoffman. “Otherwise, waivers look like little more than a tool for ideological social welfare cuts based on arbitrary determinations of who is deserving or undeserving of receiving the benefits that programs like Medicaid provide.”

Read their full JAMA Viewpoint here.