Tough Tradeoffs Under Republican Work Requirement Plan: Some People Lose Medicaid or States Could Pay to Maintain Coverage (2023)

Note: This analysis was updated on May 5, 2023 clarify an error about verification for exemptions.

On April 26, 2023, the House of Representatives passed a Republican debt ceiling bill (HR 2811, the Limit, Save, Grow Act of 2023) that includes a requirement for states to implement work requirements for certain Medicaid enrollees. Data show that 91% of non-elderly Medicaid enrollees who are not on Supplemental Security Income or Medicare are working or face barriers to work. We estimate that if the proposal were fully implemented in 2024 and the rate of Medicaid eligibility loss was as the Congressional Budget Office (CBO) estimated, then 1.7 million enrollees would not meet work or reporting requirements and potentially face disenrollment in that year. States could continue to provide Medicaid to those enrollees but would not receive federal matching funds for doing so. It is unclear if any states would choose to do that, though CBO estimated over half of enrollees would continue to be covered at the states’ expense. If states chose to keep all 1.7 million people enrolled, $10.3 billion of Medicaid spending would shift from the federal to state governments in 2024. A small number of states with the largest share of enrollees under the Affordable Care Act (ACA) Medicaid expansion would account for almost half of the increased state spending or coverage losses.

(Video) Indiana Medicaid work requirements fuel worries for the poor

What is the work requirement policy in the debt ceiling bill?

Under the Medicaid work requirement plan, certain adult enrollees ages 19-55 would need to work or participate in other qualifying activities (like community service or job training) for at least 80 hours per month. There would be exemptions for those who are physically or mentally unfit for employment (as determined by a physician or other medical professional), pregnant, the parent or caretaker of a dependent child or incapacitated person, complying with a work requirement under a different federal program, participating in drug or alcohol treatment or rehabilitation program, or enrolled in school at least half time. If enrollees fail to meet the work or reporting requirements for three or more months, the federal government would cease paying the federal share of Medicaid for their expenses. States could disenroll them or continue their coverage but pay 100% of the costs. Eligibility for federal funds could resume at the start of the following calendar year.

How would the policy affect Medicaid enrollment or spending?

The CBO cost estimate included national estimates of coverage loss and changes in federal spending but did not include state-specific estimates or details about how individual states would respond or why. CBO estimates that once work requirements were implemented, each year an average of 15 million enrollees would be subject to the new requirements and about 1.5 million of them would lose eligibility for federal funding, resulting in federal savings of $109 billion over the period. CBO anticipates that about 60% (900,000) of the people who lost eligibility would live in states that maintained coverage with state-only funds and the remaining 600,000 would become uninsured because they lived in states that did not maintain coverage. In a follow-up estimate, CBO estimated that state costs would increase by $65 billion over the 2023-2033 period in states that opt to continue coverage without federal funds (or an average of $6.5 billion annually). In summary, CBO stated that “under those requirements, federal costs would decrease, the number of people without health insurance would increase, the employment status of and hours worked by Medicaid recipients would be unchanged, and state costs would increase.”

(Video) The arguments for and against Medicaid work requirements

Assuming the policy is fully implemented in 2024 and CBO’s estimated rate of eligibility loss applies in all states, we estimate that 1.7 million people could be determined ineligible in 2024 and provide state-by-state estimates of the number of people who could potentially lose coverage. To estimate state-by-state coverage loss, we use state-by-state estimates of 2024 projected enrollment that reflect coverage losses attributable to unwinding the continuous enrollment period, which applied during the COVID pandemic but ended on April 1, 2023. We adjust those estimates to account for new enrollment during the months from April 2023 to May 2024, assuming new enrollment is similar to that of the past six months. We also adjust those estimates to account for re-enrollment of people who are disenrolled during the unwinding (e.g., “churn”) and South Dakota’s new expansion – an estimated 40,000 adults. North Carolina also recently adopted a new expansion program but implementation of the expansion is contingent on the 2023-2024 budget, so our estimates do not include North Carolina.

Consistent with the Department of Health and Human Services, we assume the work requirements would only apply in expansion states and only apply to enrollees in the expansion group, since other categories of enrollees would be exempt (e.g., children, older people, parents who qualified under pre-ACA eligibility rules, and people who cannot work due to a disability). Wisconsin is a non-expansion state and not included in the analysis; however, they do have a waiver to cover adults up to 100% of the federal poverty level (FPL) who could be subject to the work and reporting requirements.

(Video) Wyden, Casey, And Warren Accuse GOP Of 'Scheme' To Threaten Medicaid Coverage For Over 20 Million

We estimate 16.7 million enrollees in the expansion group would be between ages 19 and 55 in May 2024 using the age distribution of expansion adults in administrative data (“T-MSIS”). This estimate includes some parents of dependent children, who would be exempt from the work requirement but still potentially subject to reporting requirements. If 10% fail to meet the work or reporting requirements, as CBO assumed, 1.7 million enrollees could lose eligibility for federal matching funds in 2024.

If all states elected to maintain coverage for the 1.7 million people (rather than the 40% losing coverage as assumed by CBO), we estimate that the policy would shift $10.3 billion from federal to state spending in 2024 (state-by-state results in Appendix Table 1). It is unknown if any states would choose to maintain coverage at full state cost, making up for the loss of federal funds, and CBO did not provide any details about which states would do so under their estimates. We estimate for each state what the coverage loss would be based on CBO’s national rate, and also what it would cost each state to prevent the loss of coverage. The distribution of costs across the states is closely related to the size of states’ expansion populations and five states (CA, IL, NY, PA, WA) account for nearly half of the total costs (Figure 1). We estimated the per-person costs for expansion group enrollees in 2024 by growing 2021 per-person costs from the Medicaid CMS-64 administrative data and adjusting them upward slightly based on trends in spending through the current year to date from the U.S. Treasury outlays. We assume per-person costs in 2024 will grow at the same rate as costs in 2023. The new costs to states equal 90 percent of total spending for affected enrollees—reflecting the 90% of costs that the federal government pays for expansion enrollees who remain eligible.

(Video) Democrats have gone off the rails: Rep. Claudia Tenney

What to watch?

We used CBO assumptions to estimate the share of people who could lose eligibility for federal matching funds, but that estimate is highly uncertain. For example, if adults with dependent children who are eligible through the expansion pathway are automatically exempted from work and reporting requirements, the share that could lose eligibility could be lower than 10 percent. However, when Arkansas implemented work requirements, 25 percent of those subject to the requirements lost coverage, suggesting that the percent who lose eligibility could be well above the 10% assumed by CBO and used in our state-by-state estimates. The most likely outcome is that the actual rate will vary considerably across the states. Our estimates are also specific to H.R. 2811.

Another source of uncertainty is that the policy could be applied to non-expansion eligibility groups, which would make many more people subject to reporting requirements, such as parents and people who cannot work due to a disability. Although we anticipate that most of those people would qualify for an exemption, some could lose Medicaid eligibility on account of being unable to comply with reporting requirements. We estimate that there will be 15.3 million adults ages 19-55 in non-expansion eligibility groups in 2024, compared with 16.7 million expansion adults (state-by-state results in Appendix Table 1, tab 2).

(Video) Republicans’ Cruel Debt Ceiling Demand Exposed

While the debt ceiling bill passed the House, it is not expected to pass in the Senate. Leaders in the Senate and the Administration support passage of a clean debt ceiling bill; however, proposals to reduce federal spending could continue to be debated as part of the debt ceiling or as part of the regular budget process. It is unclear whether this policy—or similar related policies—could end up being debated as negotiations over the debt ceiling and federal spending continue.


What do liberals think about Medicaid? ›

Liberals view Medicaid as diverting the Nation's attention from the need for national health insurance. They are troubled by the fact that the program covers less than one-half the Nation's poor and that there are substantial variations in State Medicaid programs.

Which program provides financial support to states to provide health insurance to individuals who qualify based on their income? ›

Medicaid and the Children's Health Insurance Program (CHIP) provide free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Some states expanded their Medicaid programs to cover all people below certain income levels.

What is the highest income to qualify for Medicaid? ›

Federal Poverty Level thresholds to qualify for Medicaid

In 2023 these limits are: $14,580 for a single adult person, $30,000 for a family of four and $50,560 for a family of eight. To calculate for larger households, you need to add $5,140 for each additional person in families with nine or more members.

What state has the best Medicaid program? ›

In this Article
RankStateTotal Score
2New York75.99
47 more rows

What do Republicans think about the healthcare system? ›

Republicans support a health insurance system that protects Americans with pre-existing conditions, increases transparency and choice, and lowers costs.

What are some disadvantages of Medicaid? ›

What are disadvantages of accepting Medicaid?
  • Physician shortages. Depending on where you live in Florida, physicians in your area who accept Medicaid may become overwhelmed with treating qualifying patients. ...
  • No guaranteed timing for payments. ...
  • Unfair funding appropriation. ...
  • Refused procedures after services rendered.
Feb 23, 2022

Which government programs are designed to help people who are having difficulty affording health insurance? ›

Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources.

What is the government provided health insurance program that provides assistance for anyone who Cannot afford medical treatment? ›

Medicaid is a joint federal and state program that provides free or low-cost health coverage to millions of Americans, including some low-income people, families and children, pregnant women, the elderly, and people with disabilities.

What is a government program that provides free health care to the needy? ›

Medi-Cal is California's Medicaid program. This is a public health insurance program that provides free or low cost medical services for children and adults with limited income and resources.

What state has the highest Medicaid income? ›

The state with the highest income limits for both a family of three and individuals is Washington, D.C. If you live in this area, a family of three can qualify for Medicaid if their income is at 221% of the FPL. For other adults, the limit is set at 251% of the FPL.

How much money can you have in the bank and still qualify for Medi-Cal? ›

Household Asset Limits for Non-MAGI Programs as of July 1, 2022​
Household​ size​Asset limits
1 pers​on$130,000
2 people$195,000
3 people$260,000
4 people$325,000
6 more rows
Apr 14, 2023

Does Social Security count as income for Medi-Cal? ›

Unearned Income

This type of income relates to interest on savings and retirement accounts, pensions, annuities, veteran's benefits, etc. Social Security counts as unearned income as well. Gifts, royalties, and inheritances also count as unearned income.

What state is easiest to get Medicaid? ›

Main Findings
Overall RankStateQuality
2Rhode Island7
46 more rows
Mar 15, 2021

Who uses the most Medicaid? ›

As shown in the table below, children and youth represent nearly half of all people covered by means-tested public health insurance in the United States. Adults ages 65 and older, many of whom are low-income and participate in Medicaid to supplement Medicare, represent nearly 11 percent.

What state has the best medical care? ›

Hawaii is the top state for health care in the U.S. It has the best health outcomes in the country, with low preventable death (47 per 100,000 people), diabetes mortality and obesity rates. However, the state ranks fairly low for accessibility (No. 31).

What do Republicans think about the economy? ›

In Republicans' Commitment to America, they'll focus on less government spending, less taxes and regulation that drive inflation, more American-Made energy, and more workers connected to jobs, Ways and Means Republican Leader Rep.

What would happen if Medicare ended? ›

They would have to sell their assets and spend their savings to finance their health care, and their consumption levels would drop. To be willing to live in a world without Medicare, the economists estimate, the old would need to be paid $27,700 in compensation.

How do Democrats feel about taxes? ›

New Democrats believe comprehensive tax reform should: 1. Put middle class families first; 2. Support workers and enable them to invest in themselves and their jobs; 3. Simplify the tax code to enable private sector growth and small business fairness; 4.

What are two disadvantages of Medicare? ›

  • Members are responsible for copayments and deductibles.
  • May require referrals to see a specialist.
  • The provider network limits the choice of doctors/hospitals and doctors may not accept certain Medicare Advantage plans.
  • Members are required to pay full price for services outside the provider network.

What are the negative effects of Medicaid expansion? ›

One study found that expansion was associated with an 18% increase in aggregate opioid admissions to specialty treatment facilities, nearly all of which was driven by a 113% increase in admissions from Medicaid beneficiaries.

What is the challenge with Medicare and Medicaid? ›

The lack of alignment between Medicare and Medicaid benefits manifests in the contradiction of paying plans and value-based payment organizations more on a per person basis to cover dual-eligible beneficiaries, but paying providers less on a per service basis to treat dual-eligible beneficiaries.

What is the best health insurance for over 65? ›

Medicare is the best health insurance option for seniors and retirees. For those age 65 and older or who have a qualifying disability, the Medicare program will be the cheapest health insurance with the best benefits.

Can a 50 year old get Medicare? ›

Generally, Medicare is for people 65 or older. You may be able to get Medicare earlier if you have a disability, End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant), or ALS (also called Lou Gehrig's disease).

What causes lack of access to healthcare? ›

High out-of-pocket costs, even for patients with insurance, are a huge barrier to accessing health care. When people must choose between paying for food and rent or paying for health care, many forgo health care.

What happens if you can't afford healthcare in America? ›

By federal law, nonprofit hospitals must offer financial assistance to those who cannot pay their bills. Some states also have other laws about uncompensated care, such as Washington, where all hospitals must tell patients about financial assistance programs when they receive care.

Why healthcare should be free? ›

Improving the economy. Providing free healthcare would have an enormous impact on the economy. Many people do not work because they have health conditions which they cannot afford to fix. A country with free healthcare would have a stronger economy than those with pricey healthcare.

What kind of insurance can you get if you retire at 62? ›

These include Medicaid, short-term health insurance, insurance through employment, COBRA or private marketplace plans — all of which can vary in cost. Generally, marketplace health insurance for seniors without Medicare costs an average of $970 for 60-year-olds, but this can change depending on the level of coverage.

Which three government programs provide assistance to the working poor? ›

Some of the major federal, state, and local social welfare programs are: Supplemental Security Income (SSI) Supplemental Nutrition Assistance Program (SNAP) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

What is a government provided health insurance program for individuals with limited income and resources? ›

Medi-Cal is California's Medicaid health care program. This program pays for a variety of medical services for children and adults with limited income and resources. Medi-Cal is supported by Federal and state taxes.

Which level of government would help people who require assistance with basic needs such as food or medical care? ›

Federal and state governments offer a wide range of assistance programs for individuals, families, and businesses. These programs can help provide income, food, housing, healthcare, and other necessities to those in need.

What percentage of Americans get Medicaid? ›

The percentage of Americans covered by the Medicaid public health insurance plan increased from 17.8 percent in 2020 to around 18.9 percent in 2021. However the percentage of those insured through Medicaid remains lower than the peak of 19.6 percent in 2015.

What percentage of the US population is covered by Medicaid? ›

In 2021, 35.7 percent of people held public coverage for some or all of the year, marking a 1.2 percentage-point increase from 2020. Between 2020 and 2021, the rate of Medicaid coverage increased by 0.9 percentage points to cover 18.9 percent of people.

How much of the US budget goes to Medicaid? ›

Medicaid spending (not including administrative costs) totaled $728 billion in federal fiscal year (FFY) 2021 (Figure 1). Medicaid spending is shared by the federal government and states and includes spending for eligible enrollees for qualified services.

Does owning a home affect Medicare? ›

Many beneficiaries wonder if owning their home will affect their Medicare benefits. Medicare doesn't limit enrollment based on resources or income. Unless the sale of your home is taxable income, your Medicare won't be affected.

What is Magi Medi-Cal? ›

Modified Adjusted Gross Income (MAGI) Medi-Cal provides free or low-cost health care for those that meet the income requirements. The following groups may be eligible: Adults (aged 19-64) Parents/Caregiver Relatives. Children (up to age 19)

What income counts against Social Security? ›

We only count your earnings up to the month before you reach your full retirement age, not your earnings for the entire year. If your earnings will be more than the limit for the year and you will receive retirement benefits for part of the year, we have a special rule that applies to earnings for one year.

What is the Medi-Cal income limit for 2023? ›

In 2023, the MMNA in CA is $3,715.50 / month. If a non-applicant's monthly income is under this amount, income can be transferred to them from their applicant spouse to bring their income up to $3,715.50.

Does Medi-Cal count 401k as income? ›

Note: This category of Medi-Cal exempts (does not consider) some types of resources: Retirement funds like 401(k)'s and IRA's. Any money that you earn from your work while you are on the program, as long as you put that money into a separate bank account.

What is the best state to live in to get Medicaid? ›

Nationally, 21% of people receive Medicaid benefits. New York, New Hampshire and Wisconsin were found to provide the best Medicaid programs in the country.

What country has free healthcare? ›

However, Brazil is the only country in the world that offers free healthcare for all its citizens. Also, Norway is the first country in the world to implement a free healthcare policy as far back as 1912. Coincidentally, Norway is recognized as one of the healthiest countries in the world.

What state has the best senior healthcare? ›


What race is the most uninsured? ›

The U.S. uninsured rate in 2021 across race and Hispanic origin groups ranged from 5.7% for White, non-Hispanic people to 18.8% for those identifying as American Indian and Alaska Native, non-Hispanic. Hispanic or Latino people had among the highest uninsured rate in the nation at 17.7%.

What ethnicity uses Medicaid the most? ›

Distribution of Medicaid/CHIP enrollees in the United States in 2021, by ethnicity
CharacteristicPercentage of Medicaid/CHIP enrollees
1 more row
Feb 16, 2023

What state has the healthiest people? ›

1. Hawaii. Hawaii tops the list of states with the healthiest population, thanks in part to residents having the longest lifespan (80.87 years), the second lowest percentage of obese adults (24.83%) and the sixth lowest percentage of adults who smoke (11.33%).

What state has the best quality of life? ›

No. 1 state to retire for high quality of life: Massachusetts. Massachusetts is the best state for retirees based on the quality of life. While the state ranked in the bottom half of the list for affordability, it scored top marks for health care, coming in at second place.

Are more Republicans or Democrats on Medicaid? ›

#2: Public Holds Favorable Views Of Medicaid

A majority of Democrats (89%), independents (75%), and Republicans (65%) view the program favorably. The share across parties who view the law favorably has remained stable since the last time it was asked in 2019.

What is the liberal view of Medicare? ›

Elements of the liberal health care perspective include a belief that health care is an equal right of all people, the implementation of that right through a social insurance system that provides universal health coverage, equitable financing of health care, and a commitment to equality in health care.

Why is Medicaid expansion controversial? ›

The concern is that the state's 10 percent share of Medicaid expansion spending could represent a significant expenditure that the state could not afford. If taxes were raised to cover the expense, those taxes would dampen economic activity and, to some extent, harm the very people the ACA is intended to help.

What is the libertarian view on healthcare? ›

In the libertarian concept, individuals themselves are responsible for their own health, their own well‐being and the fulfilment of their life plan. Therefore, everyone pays for their own individually experienced healthcare needs, directly or indirectly through private healthcare insurance.

Who spends the most on Medicaid? ›

U.S. states with the highest Medicaid expenditure in FY 2021 (in billion U.S. dollars)*
CharacteristicExpenditure in billion U.S. dollars
New York75.4
6 more rows
Oct 4, 2022

Which states have the most people on welfare? ›

State With Most Welfare Recipients

California stands out as the state with the highest number of welfare recipients, with 1,911,000 households benefiting from SNAP. Several factors contribute to California's significant number of recipients.

Do liberals believe in gun rights? ›

Liberals believe that the Second Amendment doesn't give the people the right to bear arms, but it does allow the state to create and keep a militia to protect us from a corrupt government. They believe it is the local and federal government's duty to protect citizens.

Do Democrats want affordable healthcare? ›

Democrats believe that quality, affordable health care is a right – not a privilege – for every American.

Who supports Medicare for All? ›

The Medicare for All of 2022 has also been endorsed by more than 60 major organizations, including National Nurses United, American Medical Student Association, Nation Union of Health Care Workers, Service Employees International Union (SEIU), Association of Flight Attendants-CWA (AFA-CWA), Indivisible, Public Citizen, ...

What are the issues with Medicaid in the US? ›

Looking ahead, there are three immediate challenges facing Medicaid for the remainder of the year: eligibility and state oversight, loss of temporary coverage due to the pandemic and lack of public support.

How many states decided not to expand Medicaid? ›

The end of the Medicaid continuous enrollment provision in March 2023 and the resumption of Medicaid disenrollments after a three-year pause during the pandemic are likely to refocus attention on gaps in Medicaid coverage in the ten states that have not adopted the Affordable Care Act's (ACA) Medicaid expansion as of ...

Is libertarian progressive or conservative? ›

According to common United States meanings of conservative and liberal, libertarianism in the United States has been described as conservative on economic issues (economic liberalism and fiscal conservatism) and liberal on personal freedom (civil libertarianism and cultural liberalism).

What does the Libertarian Party think about immigration? ›

Libertarians believe that people should be able to travel freely as long as they are peaceful. We welcome immigrants who come seeking a better life. The vast majority of immigrants are very peaceful and highly productive.

Is healthcare an economic right? ›

Universal access to health care, without discrimination, is a human right enshrined in the Universal Declaration of Human Rights and the International Covenant on Economic, Social and Cultural Rights.


1. The Effects of Expiring Pandemic Relief Measures on Coverage and Affordability: A Future Outlook
(Alliance for Health Policy)
2. Medicaid Expansion Transforming Politics In Deep Red States
(The Majority Report w/ Sam Seder)
3. Health Reform: From the Midterms to 2020
(Health Affairs)
4. The Case for Medicaid Expansion in the Time of Coronavirus
(Center for Health Administration Studies)
5. GOP Work Requirements For Public Assistance Are Totally Ineffective
(The Majority Report w/ Sam Seder)
6. Health/Medicaid - New York State Budget Public Hearing


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