In a recent letter to state Medicaid directors, officials at the Centers for Medicare and Medicaid Services (CMS) encouraged states to implement work requirements in Medicaid, writing that “a growing body of evidence suggests that targeting certain health determinants, including productive work and community engagement, may improve health outcomes.”
In response, 10 Republican-led states have submitted plans to impose work requirements as a condition of eligibility for parents in Medicaid (as opposed to adults without dependent children), and 4 have been approved. This represents a major policy shift for Medicaid, which now covers 75 million people, as it has never before included a work requirement as a condition of program eligibility.
As part of the 2018 Farm Bill debate, Republicans have also proposed expanding the work requirements in the Supplemental Nutrition Assistance Program (SNAP, formerly known as the food stamp program) – the largest nutrition assistance program in the U.S., which covers 43 million people – by requiring unemployed parents with minor children to work or train for a job (the current requirement is that this group be looking for work) and by placing time limits on benefits for more adults.
It is clear that Medicaid provides financial protection from medical bills for poor families. It is also clear that SNAP reduces hunger and lifts families out of poverty. What is less clear is how work requirements for parents in these safety net programs might improve the health of poor children and families. This is a critical question worth asking, and one that is ostensibly at the root of the new waivers.
Although the inclusion of work requirements in federal safety net programs is not new, there is a new push to extend them to Medicaid and to expand the breadth of people who must comply. Work requirements gained popularity during welfare reform in the 1990s, when they were added to the Temporary Assistance for Needy Families (TANF) cash-assistance program. Also under welfare reform, work requirements were established for certain able-bodied adults receiving SNAP benefits. Since then, there has been continued interest among Republicans to extend work requirements to other safety net programs as a tool to reduce federal spending.
There is scant evidence that work requirements make a significant difference in the lives of poor families. For example, when work requirements were implemented for TANF recipients, employment gains were inconsistent and participation in the program dropped sharply. For SNAP recipients, administering the labyrinth of requirements and exemptions under the work requirements policies proved so burdensome that many states preferred not to implement them. In interviews with the Agriculture Department Office of the Inspector General [PDF], state officials described the administration of such requirements in SNAP as “error prone” and an “operational nightmare.” This raises questions about the practicality of current Republican efforts to tighten the existing work requirements in SNAP. There are a number of reasons to expect that the new work requirements in Medicaid and suggested changes to the work requirements in SNAP will not improve the health and well-being of parents and may even have negative consequences for children.
First, work requirement policies, when applied to parents as a condition of program eligibility, may have detrimental spillover effects on the health and well-being of children. Robust evidence suggests that children’s participation in Medicaid and SNAP is affected by parental coverage in these programs. For example, recent research found that Medicaid expansions targeted at adults have positive effects for children’s health by increasing children’s receipt of preventive health services. Likewise, research among families enrolled in SNAP suggests that SNAP participation actually reduced health care expenditures by an estimated $1,400 per year. This suggests that if parents are disenrolled from Medicaid or SNAP because they cannot meet their state’s work requirements, there is likely a risk that their children will lose coverage in these programs as well, likely leading to higher health care spending and increased food insecurity.
Second, recent economic data show the majority of low-income adults with dependent children are already working, enrolled in school, or are not in the workforce due to disability or retirement (see Figure). 
We analyzed 2017 data from the U.S. Census Current Population Annual March Social and Economic Supplement. Our analysis included citizens older than 21 who have any dependent children. Among families with anyone covered by Medicaid, 66% of adults reported working or going to school on a full- or part-time basis. Similarly, among families with anyone covered by SNAP, 54% of adults reported working or going to school on a full- or part-time basis.
A relatively smaller proportion of families where adults reported looking for work or not being in the workforce for other reasons (20% among Medicaid families and 27% among SNAP families) could theoretically benefit from work requirement policies if they were able to receive meaningful job search assistance or other training. Overall, these numbers suggest that for the majority of low-income adults with dependent children who are working or in school, work requirements will do nothing more than add a layer of bureaucratic complexity to maintain nutrition assistance or health insurance benefits – programs which are critically important to poor families.
There are several steps that states pursuing work-requirement policies could take to mitigate potential unintended consequences for children and families:
- At a minimum, states should monitor program utilization and coverage loss among children with a parent who loses eligibility because of noncompliance with work requirements.
- States should also consider outreach and enrollment efforts to ensure that parents subject to work requirements are aware that their children’s program coverage is not dependent on work status.
- States might also consider taking steps, such as data matching with labor departments, to reduce the administrative burden placed on parents who have to comply with work requirements. There may be ways to cross-leverage lessons learned from SNAP to Medicaid, as each state is required to operate a SNAP employment and training program (SNAP E&T). The 2014 Farm Bill established a new pilot program for SNAP E&T that awarded competitive grants to ten states to test strategies designed to enable more SNAP participants to obtain employment and reduce their reliance on public assistance.
- Finally, evaluators of the state Medicaid work-requirement policies should have a credible plan to collect data to measure which families leaving the rolls have good outcomes (e.g., obtaining other affordable family health insurance coverage) or bad outcomes (e.g., one or all family members becoming uninsured).
The value of adding work requirements to Medicaid or SNAP is highly questionable, since most working-age adults in these programs who can work already do so. If work requirements are increasingly adopted in Medicaid or tightened in SNAP, it will be important to avoid the unintended consequence of exacerbating long-standing racial and ethnic disparities in health outcomes for adults and children through reduced participation.
In the long run, rather than using the arbitrary and blunt instrument of work requirements to reduce Medicaid or SNAP enrollment, policymakers would be well-advised to consider ways to break the link of inter-generational poverty. An agenda to reduce the proportion of children and families living in poverty in the U.S. would need to stretch far beyond the details of means-tested programs and would require a deliberate focus on the underlying drivers of poverty. We believe that to be a challenge worth tackling.
Marian Jarlenski
Latest posts by Marian Jarlenski (see all)
- The new push for work requirements in Medicaid and SNAP: Implications for children and families - May 24, 2018
- Smoking in America: Medicaid, Quitting, and Income - November 20, 2017
- The Political Context of Medicaid Expansion - March 21, 2017
