June 2018 | Issue Brief
Implications of Work Requirements in Medicaid:
What Does the Data Say?
Rachel Garfield, Robin Rudowitz, MaryBeth Musumeci, and Anthony Damico
In January 2018, the Centers for Medicare and Medicaid Services (CMS) issued new guidance for state
Medicaid waiver proposals that would impose work requirements in Medicaid as a condition of eligibility.
As of June 2018, four states have approved waivers to implement Medicaid work requirements, seven
states have waiver requests pending with CMS, and other states are considering or developing work
requirement programs. These states are all imposing or seeking to impose work requirements on
populations already covered (both expansion and non-expansion populations); however, Virginia passed
legislation to adopt the Medicaid expansion that included a provision to submit a waiver to impose a work
requirement on a new expansion population. This brief builds on previous analyses to provide data on
Medicaid enrollees and some of the policy implications of work requirements. Key findings include:
Most Medicaid enrollees who can work are already working but could face barriers in
complying with reporting requirements. More than six in ten adult enrollees are working. Those in
excellent/very good health are almost twice as likely to work as those in fair/poor health. Having
higher education is also positively associated with whether someone works. However, since one in
three Medicaid adults never use a computer or the internet and four in ten do not use email, many
enrollees would face barriers in complying with work reporting requirements to maintain coverage.
Paid work can help provide family resources, but low-wage and part-time work may not be
sufficient to overcome poverty. Most working Medicaid enrollees are working full-time for the full
year and are working in low-wage service jobs with limited benefits such as sick time or health
coverage. Most Medicaid workers (78%) are paid hourly, and 36% of these hourly workers earn a
wage at or below $10/hour. Even when working, adults with Medicaid face high rates of financial
insecurity. In non-expansion states with low eligibility levels for adults, working part time at minimum
wage would lead to loss of Medicaid without access to coverage through the ACA marketplaces.
Many Medicaid enrollees who are not working could be exempt from work requirements but
would still need to navigate an exemption process. A quarter of non-working Medicaid adults
without SSI have mobility or physical limitations such as difficulty going up or down stairs (24%),
walking 100 yards (25%), sitting or standing for extended periods (27%), or stooping, kneeling or
bending (24%). Many live with daily, activity-limiting pain. Among the “able bodied,” or those in good
health or better, most say the reason they are not working is because they are taking care of home or
family or are in school.
Implications of Work Requirements in Medicaid: What Does the Data Say? 2
A small share (6%) of adult Medicaid enrollees are not already working and unlikely to meet an
exemption and thus are the stated target of work requirements. However, systems to track work
reporting and to process exemptions would apply to much larger shares of enrollees, both workers
and those seeking exemptions. States will be required by CMS to describe strategies to assist
beneficiaries in meeting work requirements but may not use federal Medicaid funds for supportive
services to help people overcome barriers to work.
Are most Medicaid enrollees working?
Most Medicaid enrollees who can work are already working. Overall, more than six in ten non-dual,
non-SSI, nonelderly adults with Medicaid work (Figure 1). Adults in excellent/very good health are nearly
twice as likely to be working as those
in fair/poor health. Not surprisingly,
Medicaid adults with higher education
levels are more likely to work.
Medicaid adults with a high school
degree (58%), some college (64%),
or a college degree (69%) were
significantly more likely to be working
than those who did not have a high
school diploma (51%). Although
“work readiness” encompasses a
range of factors, including
social/behavioral skills, technical
skills, “soft skills,” and others,
1
,
2
having a high school diploma is a
basic requirement for many jobs.
Does work help individuals to rise out of poverty?
Most Medicaid enrollees who work are working full-time for the full year, but their annual incomes
are still low enough to qualify for Medicaid. Among adult Medicaid enrollees who work, the majority
(51%) worked full-time (at least 35 hours per week) for the entire year (at least 50 weeks during the
year).
3
Most of those who work for only part of the year still work for the majority of the year (26 weeks or
more). Some people may work full-time (35 hours a week or more) but have multiple jobs. One in ten non-
SSI Medicaid workers have more than one job.
4
Among adult Medicaid enrollees who work part-time, many cite economic reasons such as
inability to find full-time work (10%) or slack business conditions (11%) as the reason they work
part-time versus full-time. Other major reasons for part-time work are attendance at school (15%) or
other family obligations (14%).
Figure 1
43%
50%
45%
24%
19%
21%
20%
13%
18%
17%
18%
22%
19%
12%
18%
41%
Overall Excellent/Very
Good Health
Good Health Fair/Poor Health
Not Working and Not in Working Family
Not Working but in a Working Family
Working Part Time
Working Full Time
Work Status among Non-SSI, Non-Dual, Non-Elderly
Adult Medicaid Enrollees by Health Status, 2016
NOTE: Includes nonelderly adults who do not receive Supplemental Security Income (SSI) and are not dual eligibles.
Data may not sum to 100% due to rounding. All values for people in fair/poor health significantly different from those for
people in excellent/very good health at p<0.001 level. Share of people in good health working full time or not working
and not in working family significantly different from excellent/very good at p<0.001 level.
SOURCE: Kaiser Family Foundation analysis of March 2017 Current Population Survey.
11.7M 7.5M 4.3M
Total Number of
People
23.5M
Implications of Work Requirements in Medicaid: What Does the Data Say? 3
By definition (that is, in order to meet Medicaid eligibility criteria), these individuals are working
low-wage jobs. Many people working full-time are still eligible for Medicaid, especially in Medicaid
expansion states, because they are working low-wage jobs. Most workers with Medicaid (78%) are paid
hourly, and 36% of them earn an hourly wage at or below $10/hour.
5
An individual working full-time (40
hours/week) for the full year (52 weeks) at the federal minimum wage ($7.25 per hour) would earn an
annual salary of just over $15,000 a year, or about 125% of poverty, below the 138% FPL maximum
targeted by the ACA Medicaid expansion. However, in Kansas and Mississippi (both non-expansion
states with low eligibility levels for parents, 38% FPL, and 27% FPL, respectively, with no coverage for
childless adults), meeting Medicaid work requirements through 20 hours of paid work per week at
minimum wage could lead to loss of Medicaid eligibility due to earnings but likely would leave them in a
job without benefits such as health coverage (and with incomes still below the poverty level, the minimum
for subsidies for coverage through ACA marketplaces).
Even when working, adults with Medicaid face high rates of financial insecurity, as they are still
living in or near poverty. Half report that they are very or moderately worried they will not have enough
money to pay monthly bills, and more
than four in ten say they are very or
moderately worried about having
enough money for housing (Figure
2), rates similar to non-working adults
with Medicaid. While income gained
from work can improve financial
security, this pattern shows that low-
income workers still face insecurity.
Further, people who meet community
engagement requirements through
training or volunteer activities will not
gain income to improve their financial
security.
Figure 2
50%
42%
50%
60%
53%
42%
52%
57%
Normal Monthly Bills Rent, Mortgage, or
Housing
Maintain Standard of
Living
Retirement
Medicaid Workers Medicaid Non-Workers
NOTE: Includes non-elderly adults who do not receive Supplemental Security Income (SSI). Differences between
workers and non-workers not significant at p<0.1 level.
SOURCE: Kaiser Family Foundation analysis of 2016 National Health Interview Survey.
Share very or moderately worried they will not have enough money for:
Financial Insecurity Among Working and Non-Working
Medicaid Adults, 2016
Implications of Work Requirements in Medicaid: What Does the Data Say? 4
Food insecurity is notably high among both working and non-working adults with Medicaid. Nearly
a third (31%) of working and 37% of non-working Medicaid adults say they sometimes or often worry that
food will run out, and high shares also report that they’ve experienced problems such as food not lasting,
having to cut meal size or skip meals,
not eating due to lack of money,
losing weight, or not eating for an
entire day (Figure 3). Overall, about a
quarter (24%) of non-SSI Medicaid
adults meet the USDA definition of
family food insecurity, meaning they
have low or very low food security.
6
While food assistance programs are
available to low-income people, these
programs do not reach everyone who
faces food insecurity; among non-
elderly, non-SSI Medicaid adults, only
36% live in a household that receives
food assistance.
7
Medicaid workers are working in
service jobs with limited benefits
such as sick time or health
coverage. Medicaid workers are
working for small firms and in
industries with historically low rates of
employer-based coverage, and within
those industries, they are largely
working in support jobs or jobs that
can be physically demanding, such
as nursing or personal care aide,
cook or waiter/waitress, janitor or
housekeeping. Other top occupations
among Medicaid workers include:
cashier, salesperson, drivers, or
customer service representative (Figure 4). Only 7% of Medicaid workers are members of a union,
8
which
generally use collective bargaining to negotiate higher wages or benefits for members. Many Medicaid
workers report limited fringe benefits: Only 30% of non-elderly Medicaid workers have paid sick time at
their job,
9
and only a third of Medicaid workers have an offer of ESI from their employer (which may not
meet affordability requirements under the ACA).
10
Medicaid workers have low rates of absenteeism: on
average, Medicaid workers report missing just 4 days of work in the previous 12 months due to illness or
injury.
11
Figure 3
31%
24%
21%
34%
21%
11%
17%
37%
33%
29%
43%
28%
16%
24%
Worry Food
Will Run Out*
Food Did Not
Last*
Cannot Afford
to Eat
Balanced
Meals*
Cut Meal Size
or Skip Meal
Hungry But
Did Not Eat
Lost Weight Did Not Eat
for Entire Day
Medicaid Workers Medicaid Non-Workers
NOTE: * Sometimes or Often true. Includes non-elderly adults who do not receive Supplemental Security Income (SSI).
All differences between workers and non-works statistically significant at p<0.05 level.
SOURCE: Kaiser Family Foundation analysis of 2016 National Health Interview Survey.
Share who say that due to lack of money they or their family:
Food Insecurity Among Working and Non-Working
Medicaid Adults, 2016
Figure 4
Number of
Workers with
Medicaid
647,000
397,000
374,000
368,000
362,000
359,000
347,000
327,000
319,000
296,000
SOURCE: Kaiser Family Foundation analysis of 2016 American Community Survey.
Occupations with Largest Number of Workers
Covered by Medicaid, 2016
Implications of Work Requirements in Medicaid: What Does the Data Say? 5
What barriers could workers face in complying with work
requirements?
Many Medicaid adults may face barriers in complying with the reporting requirements, which are
necessary to maintain coverage
under work requirement waivers.
30% of Medicaid adults report that
they never use a computer,
12
28% do
not use the internet,
13
and 41% do not
use email
14
(Figure 5), which may
pose a barrier to both gaining a job
and complying with reporting
requirements under state waivers. For
example, Arkansas’ waiver program
requires beneficiaries to set up an on-
line account and use this account as
the sole means of periodic reporting
related to work requirements and
exemptions.
Who may be exempt from work requirements?
States with approved or pending Medicaid waivers would exempt individuals with disabilities or
those who are medically frail, though waiver language does not specify how medical exemptions
will be operationalized or implemented. Many Medicaid beneficiaries have work-limiting medical
conditions but do not receive federal disability payments and therefore are not automatically exempt from
work requirements. There are high rates of functional disability and serious medical conditions among
non-SSI, non-dual eligible Medicaid adults, especially among those not working. More than a third (35%)
of those not working live with multiple chronic medical conditions such as hypertension, high cholesterol,
arthritis, or heart disease;
15
a similar share (31%) have a disability but do not receive Supplemental
Security Income (SSI);
16
and nearly half (46%) have any functional limitation, including mobility, physical,
or emotional limitations. Mobility restrictions can be severe and may limit employment options: among
those not working, a quarter (25%) report difficulty walking 100 yards, 24% report difficulty walking up or
down 12 steps, and 12% report the use of equipment or help to get around.
17
Figure 5
30%
28%
41%
24%
23%
32%
36%
32%
49%
Never Use Computer Do Not Use Internet Do Not Use Email
All Medicaid Adults Medicaid Workers Medicaid Non-Workers
NOTE: Includes non-elderly adults with Medicaid coverage who do not receive Supplemental Security Income (SSI). All
differences between workers and non-workers significantly different at p<0.05 level.
SOURCE: Kaiser Family Foundation analysis of 2016 National Health Interview Survey.
Share who say they:
Computer Use Among Medicaid Adults by Work Status,
2016
Implications of Work Requirements in Medicaid: What Does the Data Say? 6
Many people have physical problems that could limit the type of work they do, such as daily, activity-
limiting pain, difficulty standing or sitting for two hours, difficulty stooping, bending, or kneeling, using
hands or fingers, or carrying 10
pounds (Figure 6). Mental health
problems can also be serious, with
more than a quarter (26%) of non-
working, non-SSI, non-dual, non-
elderly Medicaid adults reporting
anxiety or depression,
18
and nearly
one in five (17%) reporting difficulty
going out or participating in social
activities. While many work
requirement waivers exempt people
with disabilities or who are medically
frail, it is not clear how states will
implement these exemptions or
whether all people who qualify for an
exemption will be able to navigate
that process successfully.
States also will have to administer
exemptions for all or some
enrollees who are in school or are
care takers. Even among those
unlikely to meet medically frailty
exemptions (the so-called “able
bodied”), many could be exempt for
other reasons. Among those in good
health or better, nearly two thirds
(63%) of those not working say it is
because they are in school (23%) or
are a caretaker (40%) (Figure 7).
Additional exemptions may be granted for those living in areas that experience high rates of
unemployment, areas with limited economies and/or educational opportunities, and areas that
lack public transportation. While the waivers approved to date require states to assess these areas, no
detail is provided about how these determinations will be made. Defining and applying new exemptions
may result in even fewer individuals subject to a work requirement but another layer of administrative
rules. However, how states implement additional exemptions could have disparate effects. Analysis of
proposed legislation in Michigan to impose work requirements, but exempt individuals in counties with
Figure 6
4%
6%
4%
6%
13%
10%
11%
15%
15%
20%
24%
27%
Difficulty Using Hands or Fingers
Difficulty Lifting or Carrying 10
Pounds
Pain Limits Life or Work Every Day*
Difficulty Pushing or Pulling Large
Objects
Difficulty Stopping, Kneeling, or
Bending
Difficulty Sitting or Standing for Two
Hours
Medicaid Non-Workers
Medicaid Workers
NOTE: Includes non-elderly adults with Medicaid coverage who do not receive Supplemental Security Income (SSI)
and are not dual eligibles. *Reference period is past 6 months. All differences between workers and non-workers
significant at p<0.05 level.
SOURCE: Kaiser Family Foundation analysis of 2016 National Health Interview Survey.
Physical Limitations Among Medicaid Adults by Work
Status, 2016
Figure 7
6%
25%
69%
9%
9%
8%
42%
39%
15%
30%
14%
2%
8%
9%
3%
5%
4%
2%
Excellent/Very Good
Health
Good Health Fair/Poor Health
Other
Could not find work
Going to School
Taking care of home or family
Retired
Ill or Disabled
Reason for Not Working Among Non-SSI, Non-Dual,
Non-Elderly Adult Medicaid Enrollees, by Health Status
NOTE: Among those not working. Includes nonelderly adults who do not receive Supplemental Security Income (SSI)
and are not dual eligible.
SOURCE: Kaiser Family Foundation analysis of March 2017 Current Population Survey.
3.5M 2.7M 2.7M
Total Number of
Non-Workers
Implications of Work Requirements in Medicaid: What Does the Data Say? 7
unemployment exceeding 8.5 percent, showed that the policy would have racial biases and would
disproportionately exempt whites in more rural areas compared to blacks in more urban areas.
19
What share of adult Medicaid enrollees are not working
and may not meet an exemption from the work
requirements?
A small share of adults is not already working or unlikely to meet exemption criteria. The structure
of state waiver requests frequently targets adults in good (or better) health and exempts individuals who
are parents or students, leaving a
small number of people potentially
incentivized to move into work by the
requirements. Just six percent of non-
SSI, non-elderly Medicaid adults are
not already working, are not
potentially medically frail, and do not
report not working for a reason likely
to meet an exemption (Figure 8).
20
Some in this group report they are
retired (2%), which is often related to
ill health, and others in this group
report that they are unable to find
work (2%); just 1% are not working for
another reason.
This target population is much smaller than the groups of enrollees who are already working but would
need to comply with new reporting requirements and those who could be exempt and would have to
navigate an exemption process. States will need to set up complex systems to handle the reporting and
exemption processes which could divert resources away from administrative dollars that could assist
individuals in finding work in voluntary programs. The CMS guidance is explicit that states will be
required to describe strategies to assist beneficiaries in meeting work requirements but may not use
federal Medicaid funds for supportive services to help people overcome barriers to work. It is unclear
how states will come up with the additional funds needed to address successfully the multiple barriers
(childcare, transportation, education, training, etc.) that interfere with the ability to work.
Conclusion
As of May 2018, four states (Arkansas, Indiana, Kentucky, and New Hampshire) have approved waivers
to implement a new work requirement in their Medicaid programs, seven states have waiver requests
pending with CMS, and other states are considering or developing work requirement programs. While
these states are all imposing or seeking to impose work requirements on populations already covered
Figure 8
Working Full Time
43%
Working Part-Time
19%
In Fair/Poor Health or
Not Working Due to
Illness or Disability
15%
Not Working Due to
School Attendance
6%
Not Working Due to
Caregiving
11%
Not Working for
Other Reason
6%
Notes: “Not Working for Other Reason” includes retired, could not find work, or other reason. Working Full-Time is
based on total number of hours worked per week (at least 35 hours). Full-time workers may be simultaneously working
more than one-job.
Source: Kaiser Family Foundation analysis of March 2017 Current Population Survey.
Potential Exemption Status from Work Requirements Among
Non-Dual, Non-SSI, Nonelderly Medicaid Adults, 2016
Total = 23.5 million
Implications of Work Requirements in Medicaid: What Does the Data Say? 8
(both expansion and non-expansion populations), Virginia passed legislation to newly adopt the Medicaid
expansion but also submit a waiver to impose a work requirement on the expansion population.
Data suggest that the population not working and not eligible for an exemption from the work
requirements could be narrow, but these requirements would have implications for a broader scope of
Medicaid enrollees.
Work requirements could have implications for Medicaid enrollees who are working, as they still
need affordable health insurance, may face challenges consistently obtaining enough hours, and
will still be subject to new reporting or documentation requirements to maintain coverage. Even
though most Medicaid enrollees who work are working full-time for the full year, most are working in
service jobs with limited benefits such as sick time or health coverage, and even when working, adults
with Medicaid face high rates of financial insecurity. Among those working part-time, many cannot find full
time work or have other barriers to work. These data points show that even among those working full-
time, work can be fragile, unpredictable, and may not help people rise out of poverty. Even a temporary
illness or emergency situation for those working in hourly jobs could result in failure to meet new hourly
work requirements. The subsequent loss of health coverage could exacerbate financial insecurity.
Finally, workers will need to verify work status regularly, and many Medicaid adults may face barriers in
complying with reporting requirements due to limited experience with or access to computers. Three in
ten Medicaid adults say they never use a computer, but Arkansas is requiring use of on-line accounts to
verify work status, and other states may rely on online reporting.
While exemptions may vary across state waivers, many individuals who are medically frail or in
school could be exempt from new work requirements, but they will have to navigate a process to
apply for, obtain, and periodically renew such exemptions. States will need to design and implement
complex protocols, processes and systems to manage and track such exemptions. Health status is the
strongest predictor of whether a Medicaid beneficiary works, and many Medicaid beneficiaries have work-
limiting medical conditions that do not rise to the stringent level required to receive federal disability
payments and therefore could be subject to work requirements. These limitations include mobility
problems such as difficulty going up or down stairs or walking 100 yards as well as physical limitations
such as difficulty sitting or standing for extended periods, difficulty stooping, kneeling or bending, or
activity-limiting pain. Given the nature of low-wage jobs and jobs typically held by Medicaid enrollees who
do work, physical limitations could present a barrier to employment. For example, working as a cashier,
health aide, cook, waiter/waitress, maid or janitor—among the top occupations held by Medicaid
enrollees—all require physical capacity in standing, walking, or being mobile. Medicaid beneficiaries in
good health who are not working or parents but are in school could also be exempt but would also have
to navigate the exemption process.
Many people not exempt due to health status may meet other exemptions, such as being a parent
caregiver or attending school. Most of the “able bodied” adults targeted by work requirements (that is,
those in good health or better) are already working, and many who are not working are caretakers or in
school.
Implications of Work Requirements in Medicaid: What Does the Data Say? 9
The data presented here reiterate previous analyses showing that most adults with Medicaid already
work, and most of the non-working either face health or physical limitations to doing the jobs available or
have other reasons for not working (such as school attendance or caretaking duties). Further, many
Medicaid adults face education or training limitations, but states are unable to use Medicaid funds for
work support services under new waiver guidance. People already working or exempt from new work
requirement policies may not be the target of new policies, but they will still be subject to verifying work
status or navigating an exemption process that could result in eligible individuals losing coverage at high
administrative expense for states.
Implications of Work Requirements in Medicaid: What Does the Data Say? 10
ENDNOTES
1
Harold F. O’Neil, Jr., ed. Work Readiness: Competencies and Assessment. (New York: Psychology Press), 2014.
2
Hope Clark, et al. Work Readiness Standards and Benchmarks: The Key to Differentiating America’s Workforce and
Regaining Global Competitiveness. (Iowa City, IA: ACT), 2013; available at:
http://www.act.org/content/dam/act/unsecured/documents/Work-Readiness-Standards-and-Benchmarks.pdf
3
Full-time workers include people working 35 hours or more, those who worked 1-34 hours for noneconomic reasons
(e.g., illness) and usually work full-time, and people "with a job but not at work" who usually work full- time. People
working full time may work at more than one job.
4
Kaiser Family Foundation analysis of 2016 National Health Interview Survey (NHIS).
5
Kaiser Family Foundation analysis of Outgoing Rotation Group data in 2017 Current Population Survey (CPS).
6
Family food insecurity is based on a 10-item scale of questions addressing adult 30-day food security. See
https://www.fns.usda.gov/sites/default/files/FSGuide.pdf for more information.
7
Kaiser Family Foundation analysis of 2017 CPS Annual Social and Economic Supplement (ASEC).
8
Kaiser Family Foundation analysis of Outgoing Rotation Group data in 2017 CPS
9
Kaiser Family Foundation analysis of 2016 NHIS.
10
Kaiser Family Foundation analysis of 2017 CPS ASEC.
11
Kaiser Family Foundation analysis of 2016 NHIS.
12
Question asks “How often do you use a computer?” and does not specify whether or not to include handheld
devices such as smart phones.
13
Based on questions asking “Do you use the Internet” and “How often do you use the Internet”. Questions do not
specify whether or not to include internet use on handheld devices such as smart phones.
14
Based on questions asking “Do you send or receive emails” and “How often do you check this account”. Questions
do not specify whether or not to include email use on handheld devices such as smart phones.
15
Includes people who have at least two of the following chronic conditions: Hypertension, High Cholesterol,
Coronary Heart Disease, Angina, Myocardial Infarction, Heart Condition, Stroke, Emphysema, COPD, Asthma,
Cancer, Diabetes, Arthritis.
16
Individuals are classified as having a disability they report serious difficulty with hearing, vision, cognitive
functioning (concentrating, remembering, or making decisions), mobility (walking or climbing stairs), self-care
(dressing or bathing), or independent living (doing errands, such as visiting a doctor’s office or shopping, alone). This
definition of disability is intended to capture whether a person has a functional limitation that results in a participation
limitation and is similar to measures used in other federal surveys, such as the American Community Survey.
17
Kaiser Family Foundation analysis of 2016 NHIS.
18
Based on respondents saying they feel depressed or anxious daily, weekly, or monthly.
19
Emily Badger and Margot Sanger-Katz, “Which Poor People Shouldn’t Have to Work for Aid?”, New York Times,
May 15, 2018. https://www.nytimes.com/2018/05/15/upshot/medicaid-poor-michigan-work-requirements.html
20
Defined as people who either report they are in fair/poor health or say a reason they are not working is due to
illness or disability.