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U.S. Representatives Debbie Dingell (D-MI-06) and Kristen McDonald Rivet (D-MI-08) urged the Trump Administration to protect health care access for Medicaid recipients as it begins to implement onerous work requirements included in last year’s GOP tax law, dubbed by some as the “Big Ugly Bill”, which made drastic cuts to federal health care funding in order to pay for tax cuts for the wealthiest Americans. In a letter to Health and Human Services Secretary Robert. F. Kennedy, Jr. and Centers for Medicare and Medicaid Services Administrator Mehmet Oz. the lawmakers expressed their concerns that the short timeline for implementation as well as the lack of clarity in the law will likely lead to coverage losses of about 5 million people and decreases in Medicaid enrollment. 

“Evidence from the few states that have attempted to implement work requirements demonstrate the policy’s lack of success, including in our home state of Michigan. In 2018, the Governor signed a law implementing work requirements in the state’s Medicaid expansion program. The policy was short-lived, as it was discontinued in 2020 by a federal court ruling. 80,000 individuals were at risk of losing their health care coverage within the first month of implementation, and 100,000 were expected to lose coverage in the first year of implementation,” the lawmakers said. 

“49 percent of beneficiaries were already working, and 10 percent were students or homemakers, suggesting that many of those at risk of losing coverage were already meeting the new requirements, but faced coverage loss as a result of the red tape associated with the policy,” the lawmakers continued.

The congresswomen also called out the false narrative that Americans receiving health care through Medicaid are refusing to work. The claims are often parroted by advocates for burdensome work requirements, and they fail to account for barriers to employment and the fact that receiving health care assistance does not help individuals avoid needing a job to pay for other necessities like rent and childcare. 

“Imposing work requirements on beneficiaries without offering any additional support also fails to acknowledge structural barriers to employment that may have kept them from seeking employment in the first place, such as childcare and transportation. It is a misrepresentation of reality to say that Americans are “refusing to work”. Work requirements will force vulnerable populations into employment despite not addressing the full range of barriers these communities face to employment, potentially putting them in impossible positions,” the lawmakers said.

Additional lawmakers signing onto the letter include U.S. Representatives Adelita Grijalva (D-AZ-07), Stephen  Lynch (D-MA-08), Danny Davis (D-IL-07), and Pramila Jayapal (D-WA-07). 

A copy of the letter can be found HEREand text is below:

 We write to express serious concern with the implementation of the Medicaid Work Requirements enacted in H.R.1, the Republican budget bill. In particular, the short timeline for implementation as well as the lack of clarity in the law will likely lead to coverage losses of about 5 million people and decreases in enrollment, as we have seen in other states where work requirements have been implemented, such as Georgia and Arkansas. The budget law directs states to implement a nationwide 80 hour-per-month work requirement mandate for “able bodied, working age” adults across all state Medicaid programs by December 31, 2026. As we will illustrate throughout this letter, work requirements are associated with a significant degree of negative outcomes for Medicaid beneficiaries. We strongly encourage you to take these outcomes into consideration prior to implementation, and to provide guidance for states to avoid these outcomes to the extent possible.

 Evidence from the few states that have attempted to implement work requirements demonstrate the policy’s lack of success, including in our home state of Michigan. In 2018, the Governor signed a law implementing work requirements in the state’s Medicaid expansion program. The policy was short-lived, as it was discontinued in 2020 by a federal court ruling. 80,000 individuals were at risk of losing their health care coverage within the first month of implementation, and 100,000 were expected to lose coverage in the first year of implementation. 49 percent of beneficiaries were already working, and 10 percent were students or homemakers, suggesting that many of those at risk of losing coverage were already meeting the new requirements, but faced coverage loss as a result of the red tape associated with the policy.

 The work requirement provision in the Republican budget law models its policy on Georgia’s program, Pathways to Coverage, which was launched in July of 2023. In Georgia, Pathways to Coverage is a statewide program that expanded Medicaid eligibility to adults aged 19-64 years with low incomes and simultaneously introduced work requirements for newly eligible enrollees–making them the first state to tie expansion to work requirements. They experienced no gains in Medicaid coverage or in employment rates compared with their counterparts in neighboring non-expansion states during the 15 months after Pathways to Coverage. According to data from the state, only 7,500 people in Georgia, as of May, were able to receive Medicaid out of an estimated 345,000 eligible people. When compared with a control state that expanded Medicaid without work requirements, Georgia’s program reduced coverage without increasing employment, suggesting that the red tape associated with work requirements impeded Medicaid enrollment in the state.

 In Arkansas, work requirements decreased Medicaid and Marketplace coverage by 13.2 percentage points among adults aged 30-49 years within six months, while there was no change in employment or engagement in community activities. According to the Arkansas Center for Health Improvement, more than 18,000 adults in Arkansas lost coverage because of Medicaid work requirements, out of an estimated 100,000 people who were subject to them.

 The findings in the study, paired with the extremely short turnover for implementation, raise serious concerns about the implementation of work requirements on the national scale. The findings demonstrate that Georgia did not have the intended results over two years, and that is with a longer implementation plan and less frequent compliance verifications than is permitted under the Republican budget law. The Government Accountability Office reported that Georgia’s work requirements program had spent $54.2 million on administrative costs, more than double what it spent on health care.

 According to the Kaiser Family Foundation (KFF), the work requirement provisions “raise many operational and implementation questions” on issues such as compliance verification, data matching, exemptions for “medically frail” and “special medical needs,” short-term hardship exemptions, informing individuals of requirements, and noncompliance notices. With HHS not expected to release its implementation guidance until June 2026, states are pressed for time to implement policies that will ultimately require complex systems changes and substantial coordination across sectors in the health care system. Additionally, we urge you to carefully consider the harmful consequences of the new six-month renewal cycle. The shortened timeline is likely to create substantial operational challenges for states and impose significant administrative burdens on beneficiaries, particularly given the very narrow scope of available exemptions, resulting in many eligible individuals losing coverage not because of noncompliance, but because of procedural barriers, paperwork challenges, and other administrative hurdles associated with more frequent renewals.

 As you prepare to implement this provision of the budget law, we urge you to take steps to ensure that this will exact the least harm possible on the Americans who rely on Medicaid that are subject to these requirements. We would like to request your responses to the questions below within one month of receipt of this letter.

• How will you reduce administrative burden related to reporting work requirements, and ensure that any reporting processes are accessible and easy to navigate for all communities?
• What steps will you take to reduce unnecessary coverage loss of beneficiaries because of new requirements?
  • How will you ensure beneficiaries receive timely, effective communication and sufficient resources regarding the new six-month renewal cycle to prevent avoidable coverage losses?
• Who do you plan to consult with in crafting guidance on which communities/individuals are considered “medically frail” or having “special medical needs”?
  • What steps will you take to ensure that these individuals are in fact exempt from the work requirements and are sufficiently protected against coverage losses?
  • How will you reduce administrative burden for these communities to prove their status that qualifies for exemption?
  • Are you working with or will you work with disabled individuals and their families/caregivers, providers, disability advocacy groups and other relevant stakeholders to ensure that this community is protected?

Thank you for your attention to this important matter. We look forward to your response and hope you will work closely with us to avoid coverage losses as a result of this implementation.