In 2018, the Trump administration issued a rule allowing states to tie Medicaid eligibility to employment, a first in the program’s 50-year history. The policy shift was the result of decades of work by Republicans who believe – contrary to empirical evidence – that anti-poverty measures like Medicaid discourage people from entering the workforce. Under the Trump-era rule, states could obtain Medicaid waivers that linked coverage to proof of work. But shortly after taking office, Biden rescinded the rule and withdrew state approvals for Medicaid work requirements that had been previously granted. One state, however, managed to keep its requirement: Georgia. 

In 2022, after the White House reversed Georgia’s Medicaid waiver approval, state officials sued the Biden administration, claiming it was "an unlawful regulatory bait and switch.” A federal judge sided with the state, reinstating the requirement. This made Georgia the only state in the country where Medicaid eligibility was contingent on employment status. Georgia Governor Brian Kemp (R) celebrated the ruling and said that his “innovative healthcare waiver…would better serve Georgians than a one-size-fits-all Medicaid expansion.” Under the new plan, known as "Georgia Pathways to Coverage," adults who were otherwise not eligible for traditional Medicaid and earned up to the federal poverty level could receive coverage if they had proof of employment or qualifying activities like job training. Around 290,000 individuals in Georgia were potentially eligible, officials claimed. 

But a new report from Kaiser Family Foundation Health News (KFF) finds that Kemp’s “innovative” waiver has proven costly and ineffective. The program “has cost taxpayers at least $26 million so far, with more than 90% going toward administrative and consulting costs rather than medical care for low-income people.” This amount includes $2.4 million that has been paid to Deloitte, the program’s “primary consultant.” According to KFF, Georgia officials ultimately expect the plan to cost at least $51 million, with Deloitte collecting a significant percentage. 

Program enrollment has also been extremely low. So far, only about 3,500 people have signed up for the program since it started in July 2023. This is far below the 25,000 enrollments that officials predicted the program would secure in its first year. 

If Georgia expanded Medicaid under the Affordable Care Act, at least 395,000 people would be eligible for coverage, and enrollment would be dramatically simplified. A 2021 study also found that with the federal government covering 90% of the cost, traditional Medicaid expansion in Georgia could “reduce state spending by $710 million over two years.”

Meanwhile, those who do apply face a wide array of hurdles. According to the program’s Data Tracker, 45% of applicants are still waiting for their applications to be processed. And only 13% of applicants end up receiving coverage. Even after enrollment, the program’s monthly reporting requirements and other red tape make maintaining coverage difficult, the Center on Budget and Policy Priorities found.

Despite the program’s shortfalls, Kemp is fighting to extend the program, which is set to expire in 2025, to 2028. Several other states, anticipating the possibility of a second Trump term, are also hoping to follow suit. 

Most Medicaid recipients already work

According to a KFF 2023 report, “most Medicaid covered adults were either working or faced a barrier to work.” KFF analyzed federal survey data from 2021 that stated that 61% of “nonelderly adults with Medicaid who are not also covered by Medicare and do not qualify for Medicaid as disabled under the Supplemental Security Income (SSI) program… were working full or part-time.” 

Those who were not working cited reasons including “caregiving responsibilities, illness or disability, or school attendance.” Only nine percent of those adults enrolled in Medicaid “reported that they are retired, unable to find work, or were not working for another reason.” According to KFF, “research suggests that the effects of work requirements on health and employment are likely limited” and that Medicaid work requirements are “confusing to enrollees” and “result in substantial coverage loss.” 

States hope to follow Georgia's lead in a second Trump term

If Trump is elected in the 2024 election, more states will likely follow Georgia's lead and pass work requirements for Medicaid. According to Politico, “Republicans in half a dozen states” are “laying the groundwork” for work requirements for Medicaid in preparation for a potential second Trump term. 

If Trump is elected and approves the plans, it “could cut hundreds of thousands of people” from Medicaid. Work requirements for Medicaid were invalidated by federal courts during Trump’s first administration. But Republicans believe a new conservative super-majority on the Supreme Court could greenlight work requirements in a second Trump term. 

In Mississippi, legislators are working to pass an expansion to Medicaid that could allow an estimated “123,000 uninsured adults” to qualify for Medicaid, according to KFF. But Chairman of the Senate Medicaid Committee Kevin Blackwell (R) said that a work requirement is “non-negotiable.” 

In January, Idaho Governor Brad Little (R) released a budget proposal that included work requirements for people who qualify for Medicaid through the expansion. In 2019, after Idaho voters approved Medicaid expansion through a ballot initiative, Little signed legislation that would have added work requirements. But that request was never approved. While Little’s new proposal is still unlikely to be approved by the Biden administration, it could be reconsidered if Trump is elected in November. 

Louisiana Governor Jeff Landry (R) is reportedly also considering adding work requirements to Medicaid. In South Dakota, Republican legislators are hoping that voters will approve “a work requirement for adults who are not physically or mentally disabled” through a ballot measure in November that would affect those eligible under the Medicaid expansion approved in 2022. 

Work requirements were also included in Project 2025, an outline for a second Trump administration created by powerful conservative groups, including the Heritage Foundation. Director of the Heritage Foundation’s Center for Health and Welfare Policy, Nina Owcharenko Schaefer, told Politico that the “states’ moves on work requirements demonstrate continued interest in the policy and could encourage a future Trump administration to take another look at it.”