Work requirements are a common-sense reform

Medicaid is the government programme that is supposed to help the poor afford health care. Its cost to taxpayers has skyrocketed in the last few years, consuming more than 12 percent of federal tax revenue collected by 2025.

Projected Medicaid spending from 2025-2034 (before the One Big Beautiful Bill) was expected to total $8.2 trillion, $2.7 trillion more than if Medicaid had grown proportionally to the population and inflation, according to the Tribune News Service.

Before the Affordable Care Act (Obamacare), Medicaid was a state-by-state programme and often was available only to a subset of people below the poverty line, especially mothers and children, but generally not working-age, work-capable adults. The ACA allowed states to expand Medicaid to cover every person below the poverty line and some above it, regardless of circumstances. The federal government pays 90% of the costs for those who became eligible due to the ACA expansion. Then, during the Biden administration, Congress and the president made a concerted effort to make enrolment easier, disenrolment harder, and programme integrity maintenance weaker.

For states and private plans that insured beneficiaries, there was little downside to signing up ineligible people or keeping them once enrolled. And as a result, taxpayer money was unduly shovelled into the coffers of states, healthcare providers and insurance plans. This was a significant factor in the ballooning of Medicaid.

That buildup undermined the core Medicaid mission of helping people most in need and rendered the programme less affordable to taxpayers, threatening to crowd out other priorities. That’s why Congress included reforms in the One Big Beautiful Bill that would diminish abuse and put the programme back on a path to provide care for those who need it most.

The new work requirements for Medicaid beneficiaries help accomplish this goal. Requiring able-bodied people to work as a condition for receiving this taxpayer-provided benefit is a common-sense reform. The work requirements don’t apply to beneficiaries who are pregnant, differently-abled, a child, a senior, a parent of a child younger than 14, or those who are caretakers for others. The requirements are carefully targeted only at adults who can work and are only required in states that recently expanded Medicaid.

Presumably, the work requirements will help identify and remove abuses like the 2.8 million duplicate enrolments that the Centers for Medicare & Medicaid Services identified. Many of these were Medicaid beneficiaries who remained enrolled in plans despite moving out of state and enrolling in their new home state.

There is almost certainly more dubious enrolment to prune from the programme. Work requirements will make fraudulent enrolment, whether deliberate or incidental, even harder to sustain.

Before the ACA, states eschewed coverage of capable adults because policymakers believed that people who could work should work, reserving the safety net for those who were unable. It was a work requirement by default. Now that Medicaid is available to everyone, though, a narrowly targeted work requirement is a reasonable reform.

Critics fear work requirements will impose a paperwork burden on eligible beneficiaries that will lead to massive reductions in Medicaid enrollment and, ultimately, adverse health consequences. However, these criticisms are based on scant evidence from two states: one that didn’t have enough time to set up and perfect its system before a court ended it, and the other was an add-on program. Neither state imposed the requirements as envisioned in the just-passed Big Beautiful Bill. In any case, paperwork burdens will likely not present a big problem, as private insurance companies are paid for each Medicaid enrollee and have strong incentives to ensure that everyone eligible remains signed up. The Medicaid programme desperately needs reforms to make sure benefits go to the people who need them most and at a cost that is manageable for taxpayers. Work requirements help achieve that goal without endangering access for those who need it.