Roundup of state Medicaid work requirement legislation and ballot measures in 2024

By

Emma Soukup

Legislatures in two states — Kansas and Mississippi — considered but did not pass bills to expand Medicaid in 2024. Both bills would have included work requirements. Voters in one state — South Dakota — will decide a ballot measure to allow Medicaid work requirements on November 5.

Background

Ten states have not expanded Medicaid coverage under the Affordable Care Act (ACA) enacted in 2010. Eight of the states are Republican trifectas, and Wisconsin and Kansas have divided governments. Debates around expanding Medicaid coverage often include arguments over work requirements for Medicaid eligibility. Medicaid cannot have work requirements without a Section 1115 waiver granted by the federal Department of Health and Human Services (HHS).

During the Trump (R) administration, 13 states applied for and were granted Section 1115 waivers, which allow states to implement work requirements as part of their Medicaid expansion programs. However, on January 28, 2021, President Biden (D) issued an executive order that directed the Department of Health and Human Services (HHS) to review all waivers that risk significant coverage loss. This review led to the withdrawal of all Section 1115 waivers that were granted under Trump’s administration. 

Georgia was one of the states that appealed the waiver withdrawal decision. The United States District Court for the Southern District of Georgia Brunswick Division, found on August 19, 2022, that because the Centers for Medicare and Medicaid Services (CMS) had judged that Georgia’s Pathways program was ineffective by measuring it against full Medicaid expansion rather than measuring it against current Medicaid coverage in Georgia, the CMS decision to rescind the Section 1115 waiver was arbitrary and capricious. Because of this decision in Georgia’s favor, Pathways was permitted to move forward, making Georgia the only state to have work requirements for Medicaid coverage. 

Expansion Activity in 2024:

On December 14, 2023, Kansas Governor Laura Kelly (D) proposed the Cutting Healthcare Costs for All Kansans Act to expand the state’s Medicaid program with work requirements for certain enrollees. The work requirements proposal, according to Kelly, aimed “to meet Republicans in the middle” by addressing the party’s fiscal concerns with Medicaid expansion. However, SB 355, which included the Cutting Healthcare Costs for All Kansans Act died in conference in April, leaving Kansas among the ten states yet to expand Medicaid.

Mississippi tried to pass a Medicaid expansion bill (HB 1725) that would have implemented the same work requirements as Georgia Pathways: 80 hours a month for able-bodied, single adults. The bill necessitated a request for a Section 1115 waiver. Mississippi’s bill died in conference in May. Mississippi has not expanded its Medicaid program under the ACA.

South Dakota and North Carolina expanded Medicaid in 2023. They are the states that expanded most recently. South Dakota Constitutional Amendment F, which is on the ballot in November, proposes amending the South Dakota Constitution to provide that the state may impose a work requirement on eligible individuals who are not diagnosed as being mentally or physically disabled in order to receive Medicaid under the Medicaid expansion that took effect on July 1, 2023. If the amendment passes, the state would have to be approved for a Section 1115 waiver to put the work requirements in place.

Georgia remains the only state with work requirements for Medicaid. But the state lost a case on July 15, 2024, about whether CMS was in the wrong in denying the state’s request to prolong the implementation period of the Pathways program to make up for time lost to litigation over the Section 1115 waiver. Because Georgia lost its case, Pathways is set to expire on September 30 of 2025.

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