Without Delay: Ensuring the Successful Implementation of Medicaid Work Requirements
Key Findings
- Enrollment and spending on Medicaid have exploded, fueled primarily by able-bodied adults.
- Through the One Big Beautiful Bill Act, President Trump and Congress added work requirements to the Medicaid program for the first time ever.
- Work requirements are a proven way to help move able-bodied adults from welfare to work.
- States should implement the new Medicaid work requirement without delay.
Overview
Enrollment and spending on Medicaid have soared, driven by able-bodied adults. However, without a work requirement in place, most able-bodied adults on Medicaid do not work at all.1
In July 2025, Congress passed and President Trump signed the One Big Beautiful Bill Act, which added a work requirement for able-bodied adults enrolled through ObamaCare expansion, beginning in 2027.2 Under the law, able-bodied adults between the ages of 19 and 64 must either work, train, or volunteer at least 80 hours per month, enroll in an education program at least half time, or earn wages of at least $580 per month, which is equal to 80 hours at the federal minimum wage.3 In many states, the average entry-level wage is high enough that this requirement can be met by working just eight and a half hours per week.4
However, the law allows the Department of Health and Human Services (HHS) to grant temporary “good faith” waivers to states that claim they are facing administrative hurdles to implementing work requirements in Medicaid.5 Thankfully, the Centers for Medicare & Medicaid Services (CMS), a division of HHS, has established integrity standards to limit these waivers.6
Work requirements are the most effective means of moving able-bodied adults from dependency to self-sufficiency. To maximize the effectiveness of the Medicaid work requirement, CMS should not approve any “good faith” waiver requests from states.
The Medicaid program has exploded
Medicaid enrollment and costs have skyrocketed in recent years, fueled primarily by able-bodied adults enrolled through ObamaCare expansion. Enrollment of able-bodied adults has increased from roughly seven million in 2000 to a staggering 34 million in 2024.7 Able-bodied adult enrollment has more than doubled since ObamaCare expansion went live and more than quadrupled since 2000.8
Nearly 85 percent of the enrollment growth over the last 10 years is due to able-bodied adults.9 Meanwhile, most able-bodied adults on Medicaid do not work at all.10
Skyrocketing enrollment has been accompanied by soaring costs, as more than two-thirds of increased federal Medicaid costs since 2000 are directly attributable to the enrollment of able-bodied adults.11 Even worse, able-bodied adults account for 36 percent of total Medicaid costs nationwide—more than seniors, children, or individuals with disabilities.12
The Medicaid program was on an unsustainable path, and President Trump and Congress took action to reform the program through the One Big Beautiful Bill Act.
CMS must hold the line on “good faith” waivers
Beginning in 2027, states will be required to implement Medicaid work requirements for able-bodied adults made eligible through ObamaCare expansion.13 Under the law, able-bodied adults between the ages of 19 and 64 must either work, train, or volunteer at least 80 hours per month, enroll in an education program at least half time, or earn wages of at least $580 per month, which is equal to 80 hours at the federal minimum wage.14 The average entry-level wage in many states is high enough that the work requirement can be met by working just eight and a half hours a week.15 The One Big Beautiful Bill Act also expanded work requirements to include even more able-bodied adults on food stamps.16
However, the law includes a provision that could derail timely implementation. HHS may grant temporary “good faith” waivers to states that claim they are facing administrative hurdles to implementing Medicaid work requirements. As seen in the food stamp program, there is a real risk that states will abuse temporary allowances to indefinitely delay implementing the new requirements at the state level.17
Thankfully, CMS has established integrity standards in the interim final rule that limit when these waivers may be approved.18 Under the rule, CMS will only grant exemptions to states that demonstrate “meaningful effort towards implementation” and encounter “extraordinary, severe, or unexpected issues” that hinder their progress.19 States must document these specific barriers related to “funding, design, development, procurement, or installation of necessary systems.”20
In most circumstances, states will have no credible basis to claim such barriers. By the time the Medicaid work requirement goes live, the newly expanded food stamp work requirement will have been live for more than a year.21 There is significant overlap between the able-bodied adult enrollment in Medicaid and food stamps. States that have already implemented the food stamp work requirement and received implementation funds have no justification to claim a barrier in the “funding, design, development, procurement, or installation of necessary systems.”
States will have had more than a year of experience implementing similar protocols in the food stamp program. And states have 30 years of experience with work requirements in food stamps, since they were first enacted in 1996.22 Structurally, there is no reason to delay the implementation of the Medicaid work requirement.
Work requirements work
Evidence from across the country shows that work requirements are successful at moving able-bodied adults from welfare to work.23 When states implemented food stamp work requirements, enrollment among able-bodied adults sharply declined as many reentered the labor force and found jobs, spanning more than 1,000 diverse industries.24 Within a year, earnings more than doubled, and by the second year, they had nearly tripled.25 Even better, the increased income more than offset any lost welfare benefits, leaving individuals better off financially than they were before.26
For the Medicaid program specifically, Arkansas provided the earliest blueprint of how successful work requirements could be. In 2018, Arkansas implemented a work requirement for expansion enrollees, requiring them to work, train, or volunteer on a part-time basis.27 Before the implementation of work requirements, most able-bodied adults on Medicaid in Arkansas reported no earned income.28 However, once the work requirement went live, thousands of able-bodied adults found jobs and increased their earnings well beyond Medicaid eligibility thresholds.29
Importantly, the Arkansas example also demonstrates that when work requirements are enforced, many able-bodied adults either comply with them or choose to forego the program altogether. There are millions of jobs open nationwide, yet most able-bodied adults enrolled on Medicaid do not work at all.30-31 The purpose of work requirements is to provide a smooth transition from welfare to work for able-bodied adults, and this purpose will be undermined if states are allowed to delay implementation.
The Bottom Line:
The Centers for Medicare & Medicaid Services should not approve any “good faith” waivers that delay the implementation of Medicaid work requirements.
Congress has enacted real work requirements that will help move millions of able-bodied adults from welfare to work. Work requirements have been tremendously successful when they are implemented, and states should swiftly implement the new Medicaid work requirement. CMS should not approve any good faith waivers to states seeking to delay implementation and allow work requirements to move able-bodied adults from welfare to work.
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