Medicaid work requirements a possible Biden compromise?

Published 8:23 am Wednesday, March 13, 2024

By Sid Salter

The current effort to make a partial expansion of Medicaid under the Affordable Care Act in Mississippi appears to have hit a legislative logjam in the State Senate over the issue of work requirements.

The Mississippi House version of expanded healthcare coverage for Mississippi’s working poor contains a work requirement. Senators on the other end of the Capitol worry that the House work requirements can’t or won’t be enforced by the federal government.

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Other states like Kentucky and Arkansas that have engaged in some form of Medicaid expansion have attached work requirements only to see the feds under President Joe Biden reject those requirements. Kentucky’s plan was blocked by a court order while Arkansas saw some 18,000 new Medicaid recipients fail to report their work activities and ultimately lost coverage.

The status quo nationally is that Republicans favor work requirements for the able-bodied recipients of government assistance and the Democrats generally oppose them. That’s been reliably true in the Medicaid expansion fight and particularly so in the ten states whose Republican leaders have resisted expansion – Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.

But Republicans and Democrats already have work requirement data available from the work requirements attached to the Supplemental Nutrition Assistance Program (SNAP) or more commonly called “food stamps” that have been analyzed by the Congressional Budget Office along with similar requirements in Medicaid and the Temporary Assistance for Needy Families (TANF) program.

That June 2022 CBO analysis found that “(m)aking the receipt of benefits contingent on working or preparing to work has substantially increased the employment rate of the targeted recipients in TANF during the year after they enter the program and by a smaller amount in later years. Work requirements in SNAP have increased employment less; in Medicaid, they appear to have had little effect on employment.

“Although some people have higher income because they work more to meet the programs’ requirements, other people do not meet the work requirements and are left with little income from in-kind benefits, cash payments, earnings, or other sources. Overall, the increase in total earnings from TANF’s work requirements is about equal to the reduction in benefits. In contrast, work requirements in SNAP and Medicaid have reduced benefits more than they have increased people’s earnings.

“In general, tightening work requirements would reduce federal spending by decreasing the amount of benefits provided; the extent of the budgetary savings would depend on the details of the policy. If lawmakers used the savings from tightening work requirements to increase work supports that helped recipients meet those requirements, the federal budget would change little (or perhaps not at all),” the CBO analysts concluded.

The shorthand on all that is that work requirements aren’t as effective as we as taxpayers are led to believe. Recipients struggle to understand or comply with reporting requirements, the bureaucracy and red tape are confusing, and many drop off the rolls over time. That’s a bad outcome for healthcare, but it does help balance the fiscal growth of the overall program.

But in red states, work requirements satisfy our strong beliefs about the able-bodied having a work ethic and government assistance being temporary.

For Mississippi lawmakers, it would seem that their efforts toward installing a work requirement in Medicaid will be bolstered either by the Biden Administration compromising and seeing expanded coverage being worth accepting the work rules during a tight election year OR by the re-election of former President Donald Trump whose administration granted Section 1115 waivers and allowed work requirements.

The Supreme Court had been set to review the legality of Medicaid work requirements in 2022 focused on Arkansas and New Hampshire actions, but dropped the case when the Biden Administration threw out most Trump-driven Section 1115 grants of waivers for work requirements.

Now Biden the Candidate must decide if those same work requirements could help him close the Medicaid expansion gap in the red states. All the while, Mississippi taxpayers are through their federal taxes already paying for expanded Medicaid benefits in 40 other states while our own working poor are not eligible for those same benefits.

Sid Salter is a syndicated columnist. Contact him at