State-level Legislation Increases the Potential Harm of Federal “Optional Work Requirement” Proposals
Requirement proposals
Some Republican members of Congress are considering changes to Medicaid legislation to allow states to impose mandatory work requirements. Work requirements don’t help people get and keep jobs, they only take away health insurance. If work requirements were implemented nationwide, it is estimated that 36 million Medicaid-eligible adults, including disabled individuals, parents and caregivers, would lose their coverage. Despite the serious problems associated with work requirements, proposals to implement them continue to be made. Since 2017, eight federal Medicaid work requirement bills have been introduced. While many of these bills are variations on the same theme, they can be divided into two groups. Those that would impose mandatory requirements on Medicaid recipients and those that are “optional” to states. Make no mistake, optional work requirements are not an alternative that is benign. If Congress creates an option for states to impose work restrictions, many will quickly take up these cuts and cause millions to lose their health care.
State Efforts in Progress
While “optional” work requirements may seem less severe, conservative groups have spent years pushing to cut Medicaid funding, leading many states to pass or introduce laws to impose work requirements. These laws say that states must either impose work requirements through a State Plan Amendment if permitted or apply for a Section 1115 demonstration waiver to impose work requirements.
The Foundation for Government Accountability has been pushing model state-level work requirement legislation since 2018. Trigger laws are gaining momentum[1]
Some state have also passed or proposed trigger laws that will impose work requirement if Congress or CMS (through Section 1115) allows it. These laws say that if Congress green lights the option, states must impose work requirements immediately
For example, in 2023, North Carolina passed a trigger law, automatically imposing work requirements if the federal government allows them. North Carolina’s residents will have no choice if Congress allows work requirements. The state has already committed to imposing them. This is because North Carolina has a law on the books that would immediately trigger work requirements.
Roughly Half the States Likely Impose Work Requirements
In addition to states that have laws on the books or may adopt them this session, other states have loudly signaled interest in imposing work requirements. We estimate that approximately half of the states are at serious risk of imposing work requirements. This includes two states with trigger laws and eleven other states with active or recent (within the past two years) legislative proposals involving work requirements. These states include two with trigger laws and eleven states that have active or recent (within the past two years) legislative proposals involving work requirements.
Though past is not necessarily prologue, and state elections can change priorities, our estimate of states likely to pursue work requirements also includes 23 states that have applied for waivers to impose work requirements in the past and two additional states that have given some other strong indication of interest in pursuing work requirements.
In several cases, courts have invalidated the approval of Section 1115 projects that have included work requirements.[2] This category includes states that have legislation authorizing the state to seek a waiver or SPA, legislation expanding Medicaid on condition of seeking a work requirement, and legislation repealing Medicaid Expansion unless a work requirement is imposed by a certain date.[3]
[1] States may have more than one indicator.
[2]Trigger Law Enacted
[3]Recent Legislative Proposals
| Exec. Commit | 1115 Applications | 1. Alabama | 1 | |
| 2. Arizona | 1 | |||
| 3. Arkansas | 1 | |||
| 1 (extension request pending) | 4. Georgia | 1 (statement for renewal in progress) | ||
| 5. Idaho | 1 | |||
| 1 (pending) | 6. Indiana | 1 | ||
| 1 | 7. Iowa | 1 | ||
| 1 | 8. Kansas | 1 | ||
| 1* | 9. Kentucky | 1 | ||
| 10. Maine | 1 | |||
| 1 | 11. Michigan | 1 | ||
| 12. Mississippi | 1[4] | |||
| 1 (pending) | 13. Missouri | 1 (enacted) | ||
| 14. Montana | 1* | |||
| 15. Nebraska | 1 | |||
| 16. New Hampshire | 1 | |||
| 1 | 17. North Carolina | 1 | ||
| 1 | 18. Ohio | 1 Oklahoma | ||
| 1 (pending) | 20. South Carolina | 1 | ||
| 1 | 21. South Dakota | |||
| 1 (enacted) | 1 (pending) | 22. Tennessee | ||
| 1 (pending) | 23. Utah | 1 | ||
| 24. Virginia | 1 | |||
| 25. West Virginia | 1 | |||
| 26. Wisconsin | 1 | |||
| Totals | 2 | |||
| 11 | 2 | |||
| 23 | * State has an application for work requirements moving through the notice and comment process. Georgia has also been approved to impose work restrictions through September 30, 2025. The potential harm to beneficiaries would be significant and far-reaching if these restrictions were allowed by the majority of states. Congress should think carefully before making changes to Medicaid that will take away health care from millions of people. | Appendix A | Recent Legislative Proposals | H.B. 419, 66th Leg., 2d Reg. Sess. (Idaho 2022). |
H.B. 1023, 124th Gen. Assemb., 2d Reg. Sess. (Ind. 2025)
S.F. 363, 91st Gen. Assemb., Reg. Sess. (Iowa 2025)
H.B. 2556, 2024 Leg., Reg. Sess. (Kan. 2024)
L.D. 1194,131st Leg., 1st Reg. Sess. (Me. 2023)
H.B. 1725, 2024 Leg., Reg. Sess. (Miss. 2024).
S.J. Res. 43, 102d Gen. Assemb., Reg. Sess. (Mo. (A constitutional change will appear on the ballots in November 2026). 134-FN, 2025 Leg., Reg. Sess. (N.H. 2025).
Ohio Rev. Code SS 5166.37 (N.H. 2025).
Ohio Rev. Res. 501, 99th Leg., Reg. Sess. (S.D. 2024).
H.B. 3485, 86th Leg., Reg. Sess. (W. Va. 2023).
Executive Commitments
Stephen Gruber-Miller, Iowa Gov. Kim Reyolds Proposes Classroom Cellphone Ban, Medicaid Changes, Des Moines Reg. (Jan. 14, 2020), available at McMaster Requests Medicaid Requirements, WPDE, (Dec. 18 2024), South Carolina Looks To Impose Medicaid Requirement under Trump Administration, WIS News 10, (Dec. 18 2024),
,
,
