Republican lawmakers continue to promote Medicaid work requirements under the banner of fairness and personal responsibility. The premise is simple enough: if you can work, you should. But that premise collapses under pressure—economic, operational, and moral.
The bitter truth is this: Medicaid work requirements don’t promote work. They undermine it. They strip coverage from people who already work in unstable or invisible ways. They push hospitals into financial distress. They drive up the cost of employer-sponsored insurance. Paradoxically, they shrink the number of jobs available in the communities where work is hardest to find.
I say this as someone who’s been inside the system. I serve on Vermont’s Green Mountain Care Board, where I’ve seen how Medicaid policy ripples through hospital budgets, insurance rate-setting, and local economies. I also teach at Dartmouth, where I work with future healthcare leaders trying to navigate the contradictions we inherit from policy choices like this one.
Consider the mechanics of the policy. To retain Medicaid coverage, adults without dependents must work, train, or volunteer for at least 80 hours per month. But the burden of proof falls entirely on the enrollee. In Arkansas, the first state to try this, 18,000 people lost coverage in months, not because they weren’t working but because they couldn’t navigate an online reporting system. That’s bureaucracy weaponized.
Most people on Medicaid already work. According to a 2023 analysis from the Kaiser Family Foundation, nearly two-thirds of adult enrollees are in the labor force, often in jobs with unstable schedules, unpredictable hours, and no benefits. The rest are mainly dealing with illness, disability, or caregiving. What a work requirement doesn’t add more employment, just more red tape. People who already work will have to prove it every month, often through systems they can’t easily access. And because their jobs are unstable, even small changes, like a missed shift or a broken login, can cause them to lose coverage, making it even harder to stay employed. People pushed out of work—not for refusing to work, but because of administrative red tape or layoffs as the economy slows—will lose their healthcare coverage.
This isn’t data from a liberal think tank. The Congressional Budget Office estimates that national implementation would result in 1.5 million people losing coverage. Some policymakers see that as a win—$109 billion in savings over ten years. But what looks like savings on paper comes at a real cost to state economies and public health systems.
Hospitals rely on Medicaid to keep their doors open. When coverage drops, uncompensated care rises. That hits rural hospitals first and hard. Many are already on the brink of closure, especially in red states.
And here’s where the contradiction becomes impossible to ignore: Hospitals are not just providers of care. They are employers. In many communities, they are the largest employers, not just of surgeons and administrators. They hire food service workers, receptionists, janitors, and home health aides—jobs held disproportionately by Medicaid enrollees. When hospitals cut costs to stay solvent, these workers are the first to go.
Take Georgia. In 2023, the state launched the country’s only active Medicaid work requirement. The program cost tens of millions, yet it enrolled fewer than 3,000 people in its first six months. The administrative barriers were so steep that most of those eligible never completed the process. That’s not reform—that’s restriction.
So, the policy circle closes on itself. We tell people they need to work to get care, take away the care that makes work possible, and eliminate the jobs they would need to qualify.
This isn’t just a rural story. National employers like Walmart and McDonald’s rank among the top beneficiaries of Medicaid, with thousands of their low-wage workers relying on public health insurance. These workers are employed, but their jobs don’t provide enough hours, wages, or stability to meet bureaucratic thresholds or afford private coverage.
This is not an abstract concern. Yale economist Zack Cooper has shown that a 1 percent increase in hospital prices leads to a 0.4 percent drop in employment in the surrounding economy. In concentrated markets—common in red states—hospitals raise prices to offset Medicaid losses. Employers facing rising insurance premiums driven by skyrocketing hospital prices, in turn, respond by cutting jobs, reducing hours, or dropping coverage.
The work requirement becomes a trap. Those who fall into it are not freeloaders or frauds. They’re part-time service workers, gas station clerks, and personal care aides—people whose hours fluctuate, whose schedules are unstable, and whose labor is essential but undervalued.
This isn’t a minor glitch in an otherwise sound policy. It is a structural failure, engineered by ideology and sustained by indifference.
If we want to promote work, we should stabilize coverage, simplify eligibility, and stop punishing people for the volatility of the low-wage labor market. The data is clear: when people stay insured, they are more likely to stay employed. If the goal is work, coverage is the tool—not the obstacle.
Medicaid work requirements are a talking point. But governing requires more than rhetoric. It requires asking what kind of economy we’re building—and who it’s leaving behind.
