Who’s Affected by Medicaid Work Requirements? It’s Not Who You Think

Since the Affordable Care Act (ACA) Medicaid expansion passed in 2010, Medicaid work requirement proponents have sought to convince policymakers that the Medicaid working-age adult population is dominated by young, “able-bodied” adults who simply don’t work. This assertion is contrary to a mountain of evidence showing that the vast majority of working-age adults (aged 18-64) insured through Medicaid are either working, caring for family members, or exempt because of health issues. 

Nonetheless, these baseless claims persist. Using what the authors cite as “responsive records” supplied by 23 states, a new report from the Foundation for Government Accountability (FGA) argues that “most Medicaid beneficiaries do not work at all.” Legally, a “responsive record” is a term of art under the Freedom of Information Act meaning a “record provided by a government in response to an information request.” FGA provides no information regarding what kind of records they examined, how they were analyzed, or any other indication of their reliability or accuracy or even their relevance to the question of the work status of Medicaid beneficiaries.

The FGA study also fails to offer any insight into the real question: Who exactly are these “able-bodied” Medicaid-enrolled working-age adults who do not work, how many of these adults actually exist, and what are their characteristics? 

This information is essential if the goal is a policy that promotes work and community engagement without punitive measures that fail to account for who the population is and wrongfully deprive people of access to health care. Overwhelming evidence shows what can happen under broad mandates that tie health care to compliance with work reporting: Affected people, including workers and potentially exempted people are unable to navigate the reporting maze, lose their health care, uninsurance rates rise, and employment rates don’t change.   

Creating an Accurate Portrait of Nonworking “Able-Bodied” Adults

To provide more detail regarding the question of who exactly are working-age, but nonworking, “able-bodied” Medicaid adults, we analyzed data from the 2023 American Community Survey (ACS), the Census Bureau’s gold standard annual population survey and the premier source of highly detailed information about Americans. The survey contains information collected from over 3.5 million households regarding multiple aspects of life, including income, health and health care, family and living arrangements, and work status.  

Our focus was working-age adults who live in the community and who are enrolled in Medicaid. Within this population, we undertook three basic comparisons: (a) Medicaid enrollees versus their counterparts who are not enrolled in Medicaid; (b) Medicaid enrollees who work versus those who do not work; and (c) nonworking “able-bodied” Medicaid enrollees versus able-bodied enrollees who do, in fact, work. For the purpose of this analysis, we focused especially on the able-bodied question. We define the term “able-bodied” individuals as people who report no health issues, do not receive either Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) because of disability, do not have dependents under 18, and are not currently attending school. These attributes basically describe the population of interest among Medicaid work mandate proponents.

Here is what our analysis revealed:

• Medicaid enrollees classified as able-bodied represent only 15.8% of the total nonworking Medicaid population ages 18-64 (and only 8% of the total Medicaid population). In other words, nonworking able-bodied enrollees are a very small part of all nonworking enrollees; the great majority of nonworking enrollees have serious health problems, care for minor children, or have a condition severe enough to qualify for disability benefits.   
• Within this small slice of nonworking adults who can be considered able-bodied, four in five (79.2%) are women, with an average age of 41. One in four (26%) is over age 50. Their median income is zero. They live in families with annual incomes averaging under $45,000 and an average household size of 4.4. In other words, they are exceptionally poor women on the older end of the working-age spectrum, who have no income of their own and live in poor families.
• This group includes many former workers. Over half (56.2%) worked within the past five years, but eight in ten (81.9%) are no longer in the labor force.
• Most have less than a high school education and have left the workforce to take care of family members, such as elderly parents or adult children or spouses with disabilities or a combination of the three.

In sum, “able-bodied” adults are a small portion of working-age Medicaid enrolled adults ages 18 to 64. They are not healthy young adults just hanging out. Although they may not have current health problems, many are middle-aged women or older, and a quarter are older than 50. They are very poor, have limited education, the majority once worked, most have left the workforce, and now they care for family and cannot afford to lose their own health care.  

Off-Base Medicaid Work Mandates

The most recent iteration of a federal work mandate, the 2023 House-passed Limit Save Grow Act, aims to penalize states that are unable to get people like these women to work. The bill would claw back hundreds of billions of dollars over time from states unable to prove that their working-age population is either exempt or working. The proposal rests on an assumption that there are tens of millions of healthy working-age adults enrolled in Medicaid who could work and do not.

Our robust analysis of the gold standard ACS data tells a dramatically different story. 

First, working-age adults who could be classified as “able bodied” because they report no health problems, no advanced disability, and no dependents at home, represent only one in seven working-age Medicaid adults. 

Second, they are not young people who choose not to work. They are older women (26% over age 50) who once worked but left the workforce to stay home and care for family. 

Third, they are very poor, with limited education. They are reaching the end of a job life. Given the demands and hardships they face, they have limited time, ability, or opportunity to transform themselves into dynamic workers earning decent wages with job-based health insurance. Finally, because they are older, they are entering a period of life when it is absolutely essential, given who they are and how much their families depend on them, that they not experience needless disruption in their health insurance in furtherance of a punitive, mandatory work policy bearing no relationship to reality. Moreover, from a purely federal budgetary perspective, it is vital to keep this group of people stably insured. Many will enter Medicare in the not-too-distant future, and the evidence shows that Medicare—and therefore American taxpayers—will bear the financial consequences of depriving this group of health care access now. We simply cannot afford a Medicaid work mandate that will do nothing to increase employment and only serves to disinsure vulnerable, impoverished older working-age women on whom their families depend.

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