Medicaid Work Requirements: Lessons from the 2018 State Legislative Sessions - Families Usa Skip to Main Content

Medicaid Work Requirements: Lessons from the 2018 State Legislative Sessions


When the Trump administration gave the green light to Medicaid work requirements, conservative lawmakers in state legislatures across the country grasped the chance to impose punitive restrictions on families relying on Medicaid. As a result, the issue of Medicaid work requirements became a hot topic in the 2018 state legislative sessions.

With over 40 bills relating to Medicaid work requirements in almost 25 states, legislative sessions had mixed results. In several states, advocates beat back these efforts, while in others, lawmakers were put on the defensive after they adopted punitive restrictions that will take away a family’s coverage for doctor visits and other health needs.

State legislation mandating work requirements will now have to take into account a federal court ruling barring approval by the Center for Medicaid and Medicare Services (CMS) of a waiver granted to Kentucky.  On June 29th, the Federal District Court for the District of Columbia ruled that Kentucky’s waiver adding work requirements to Medicaid cannot go forward because work requirements are inconsistent with Medicaid’s objectives of furnishing medical care. The judge ordered CMS to reassess the waiver’s approvability consistent with the ruling. The ruling is only on CMS’s approval of Kentucky’s waiver, but has implications for all states considering work requirements.

Using the right messages matters when opposing work requirements

Messaging about the cost to the state of placing the burden of work requirements on families who need health care coverage was one of the key tactics used to sway conservative lawmakers to oppose their own colleagues’ proposed legislation. In fact, when asked what tactics attributed to the successful defeat of work requirement legislation in Colorado, Adam Fox from Colorado Consumer Health Initiative said that highlighting the costs of implementing work requirements played a key role. “What ended up being a really pivotal messaging point to get Republicans to vote against the bill was the administrative burden [of enforcing Medicaid work requirements] on county offices and how infeasible it would be to do that without financial resources from the state.”

By using this messaging and having trained spokespeople and individuals ready to testify ahead of Colorado’s legislative session, advocates were able to proactively put pressure on lawmakers to sway their stance on work requirements, and ultimately, defeat the legislation.


In Minnesota, the legislature’s leadership held a press conference to announce plans to move work requirements in the 2018 session. A strong and diverse #ThisIsMedicaid coalition emerged to take on the powerful speaker and committee chairman. By highlighting just how unaffordable work requirements would be and the stories of people who would lose coverage, the coalition convinced legislators to not implement these barriers to coverage for their constituents. In the end, the measure won approval in committees but was unable to get sufficient support to move to the floor.


Medicaid expansion was also a factor in some states when it came to work requirement legislation. In Virginia, leaders of the Republican majority said they would only support a Medicaid expansion plan if a compromise could be reached on work requirements. While Virginia health care leaders announced opposition to work requirements early in the legislative session, in order to pass expansion, some conservative policy options had to be accepted to achieve a bipartisan win. However, coverage for the Medicaid expansion population will actually begin before the work requirements are in place. As Jill Hanken from the Virginia Poverty Law Center pointed out, “This gives everyone a chance to see the benefits of the new coverage before work requirements are implemented.  Since the development and approval of the waiver will take a longer time, the focus can now turn to getting individuals enrolled as quickly as possible and finding ways to keep them enrolled.” This provides an opportunity to expand coverage before access becomes restricted, allowing more individuals to take part in the Medicaid expansion.


Unlike Virginia, Tennessee chose to implement work requirements without expanding Medicaid this session, and as Gordon Bonnyman of the Tennessee Justice Center noted, “If anyone was going to pick a state to amp up work requirements in, this would be the last state to do it in.” When HB 1551 was introduced, advocates knew there wasn’t a strong chance of defeating the bill because it was a pet project of the state legislature’s speaker of the house, who was running for governor. However, they did want to let legislators know that it wasn’t going to be easy to take away people’s coverage.

Danielle Alaimo, a mother and full-time caregiver for her four-year-old son with chronic, life-threatening medical conditions, showed how the work requirements would harm families who need health care. Danielle’s story and efforts to fund the work requirements bureaucracy using funds intended for needy families prompted a backlash which put the bill’s sponsors on the defensive. Even though the bill was ultimately signed into law, there are indications that the state’s Medicaid agency is in no hurry to obtain a waiver. The Medicaid director has said it is up to the federal government to determine if Tennessee can fund the program using the funds for needy families.


One state is taking a more pro-active approach to stopping work requirements. In California, legislation is moving ahead to prevent the state from imposing work requirements on those in the Medi-Cal program. The Golden State legislators hope to send a message, not only to the state Medicaid program, but also to other states: that when it comes to health care, work requirements don’t work.

Be sure to check out Families USA’s Medicaid Waiver Strategy Center to learn about more ways you can protect your state from harmful barriers to Medicaid, now and in the future.

Click here to download this fact sheet.