By Jaymie Baxley
The possibility of North Carolinians who depend on Medicaid being subject to a work requirement to keep their coverage has grown more plausible with the U.S. House of Representatives’ passage of a GOP-backed budget bill that includes the measure.
Legislation approved by the U.S. House on May 22 would require “able-bodied” adults enrolled in Medicaid, which provides health insurance to more than 3 million people in North Carolina, to prove that they work, volunteer or attend school for at least 80 hours a month.
Exceptions would be made for children and their caretakers, pregnant women, people with disabilities and seniors, among other groups.
All 10 Republican members of North Carolina’s congressional delegation voted in support of the bill. It now heads to the U.S. Senate, where it is expected to face more resistance from conservatives who worry about changing the popular and widely used health care program.
Implementing and enforcing the proposed requirement could be expensive for the state, which would likely need to invest millions of dollars in new administrative systems to track compliance, verify exemptions and respond to appeals. Local and county social services offices would need to hire staff to routinely check beneficiaries’ employment status, adding to the cost.
Many health policy experts have questioned the value of that investment. An estimated 92 percent of Medicaid participants are already “working, in school, disabled or serving as caregivers,” according to the N.C. Department of Health and Human Services.
A ‘burdensome’ proposal
Antonia Pedroza, interim director of social services for Wake County, said her agency hasn’t done much to prepare for the possibility of a work requirement.
There’s not much it can do without guidance from the General Assembly, she said. The bill in Congress gives states broad flexibility to decide how long a person would need to be employed to qualify for coverage and how often they would need to show proof of continued employment to stay enrolled.
“When I say we haven’t prepared or we’re not getting ready, it’s because with the work requirements and with the passing of the legislation, North Carolina would have to write the rules,” Pedroza said.
More than 218,500 people are covered by Medicaid in Wake County; Pedroza does not know how many of them are employed. However, she noted, more than half of the county’s beneficiaries would be exempt from the work requirement because of their age.
“So many of our beneficiaries are children or are 65 and older, and obviously it doesn’t impact them,” she said.
That’s true for the state overall. About 1.4 million Medicaid participants in North Carolina are 18 or younger, according to data from NC DHHS, while more than 274,704 of the state’s enrollees are seniors.
State Rep. Donny Lambeth (R-Winston-Salem), who in March sponsored a bill calling for the “expedient implementation of Medicaid work requirements,” said he envisioned the state’s version of the measure having similar exemptions to those laid out in the congressional House bill.
“It will all depend on, quite frankly, what the federal folks say a work requirement is,” he said in an interview with NC Health News. “But what we envisioned before was, number one, obviously, you’re working and you can prove that. Number two is there were exceptions that allowed [you to enroll] if you were in a program where you were actually working towards a certification or degree, and you could prove that.
“If you did volunteer, that would qualify.”
U.S. House Speaker Mike Johnson has said the requirement will “return the dignity of work” to young, unemployed men on Medicaid. But women make up the majority of beneficiaries in North Carolina, accounting for 55 percent of the state’s enrollment.
Pedroza believes the measure would pile more work on her already overextended staff.
“It would add work to a group of people who are already working eight hours a day and are kept busy eight hours a day,” she said, adding, “Reaching out to clients and asking them if they would like our assistance in obtaining work. Making sure that they understand what the work requirements are, when they’ll go into effect and how they might be impacted — all of those things become part of our job.”
Pedroza said her staff would need to undergo extensive training if the requirement is enacted. The agency would also be forced to hire additional staff to help clients “find either employment or training that would satisfy those work requirements,” she said.
She and her team will be under a tight schedule. The legislation passed by House Republicans would require states to have their systems in place by the end of 2026.
“We’ll do what we need to do to ensure that our clients understand these work requirements and that we get the work done,” Pedroza said. “It is burdensome and it is more work, but we’ll do what we need to do.”
Uncharted territory
A Medicaid work requirement would be new for North Carolina, and only a handful of states have attempted similar measures in recent years. Results have been mixed.
More than a dozen states were issued waivers that allowed them to enact work requirements during President Donald Trump’s first term, but the effort was derailed by the COVID-19 pandemic, which extended coverage to people who needed it, with few restrictions.
Arkansas was the only state that went through with the policy. About 18,000 people there lost coverage before the measure was blocked by a federal judge in 2019. The state’s waiver was later rescinded by President Joe Biden’s administration.
A study published in the journal Health Services Research in April found that Arkansas saw “no significant change in employment or work effort” while the requirement was in place.
Georgia is the only state that has something resembling a work requirement. The policy applies to people participating in the state’s Pathways to Coverage program, which allows residents whose incomes exceed Georgia’s strict limit for Medicaid to enroll if they are working, in college or performing at least 80 hours of community service each month.
Officials expected more than 240,000 people to participate in the program, which launched in July 2023, but enrollment has fallen far short of that goal. Only 7,000 Georgians were actively enrolled as of March 31.
An analysis published in February by ProPublica and The Current found that Pathways to Coverage had cost taxpayers more than $86.9 million since its inception, with most of that money going to consultants’ fees.
At least one state has seen positive results from a Medicaid-related employment program.
Montana’s HELP-Link program, established in 2016, offers a different approach to connecting beneficiaries with work. It is not a work mandate. Instead, HELP-Link provides voluntary employment support services to people enrolled in the state’s Medicaid expansion program.
Administered by the Montana Department of Labor and Industry, the initiative helps participants access job training, career counseling and placement assistance without threatening their health coverage.
The program has earned praise for improving workforce participation while maintaining continuity of care. A 2021 evaluation by the Montana Department of Public Health and Human Services found that Medicaid expansion enrollees who participated in HELP-Link were more likely to find jobs and stay employed compared with those who did not.But the future of the program is uncertain. The 2015 law that expanded Medicaid in Montana and created HELP-Link is set to sunset next month unless the state legislature votes to extend it.
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