The Republicans’ budget reconciliation bill making its way through the House of Representatives is almost certain to cut Medicaid in a number of ways—one being that it would require the program’s low-income recipients to work at least 80 hours a week to receive health care. To Democrats, this proposal is a pernicious attack on one of the country’s most important social spending programs. But a wide swath of Americans, while opposing deep cuts to Medicaid, support the idea that working-age adults without disabilities should have to get a job to receive benefits: A February poll from the health research nonprofit KFF found that 62 percent of adults approved of the idea, a finding in line with previous polling on the issue.
There are a lot of problems with attaching work requirements to such programs, as demonstrated by states that have tried to do it. But the effort also highlights an overarching problem for Democratic messaging on many fronts: Something that sounds simple and common-sensical to many Americans is, in fact, far more complicated. Democrats have to work doubly hard to explain why something like work requirements are actually bad.
When it comes to Medicaid, the truth is that most recipients who can work already do. Federal data shows that in 2023, 44 percent of recipients worked full time, another 20 worked part time, and another 12 percent couldn’t work because they were family-caregivers, like those who have young children in the home. The rest were disabled, in school, retired, or looking for work and couldn’t find any. Many of those who work and receive Medicaid are on the program simply because they can’t afford private insurance—a problem the Affordable Care Act was meant to address. The ACA’s Medicaid expansion raised the eligibility level for childless adults to 138 percent of the federal poverty line, bringing much of the working poor into the program. (Prior to the ACA, federal law didn’t require states to cover childless, non-disabled adults.)
It’s that expansion that Republicans on Capitol Hill are now taking aim at, arguing that it has distracted from the purpose of Medicaid. “The increased share of welfare spending dedicated to able-bodied, working-age adults distracts from what should be the focus of these programs: the truly needy,” four Trump officials, including Health and Human Services Secretary Robert F. Kennedy and Dr. Mehmet Oz, wrote in The New York Times on Wednesday. Calling Medicaid “welfare” is quite deliberate. The Trump administration wants Americans to equate it with the cash assistance program that was demonized by the Reagan administration and dismantled under Bill Clinton’s 1996 “welfare-to-work” law.
Since most adults who receive Medicaid are already working, it might seem like work requirements don’t matter. But problems surface in requiring recipients to prove to the government that they’re working—by uploading documents to buggy, poorly designed websites or going in person to a county office. The GOP bill currently would require recipients to do that twice a year (up from once a year, as most states require). The recertification process itself knocks otherwise eligible recipients off federal programs because its onerousness and processing errors.
We know this because several states have imposed work requirements on Medicaid. In Arkansas, 18,000 people were kicked off Medicaid because of the work requirements after six months, despite many of them still being eligible, and 17,000 were disenrolled in New Hampshire after two months, despite the state trying to prevent the problems Arkansas had. (Arkansas’s work requirements were shut down in 2019 by a federal judge—in fact, by District Court Judge James Boasberg, who has been a thorn in Trump’s side in his second term, too. New Hampshire suspended its program shortly after it went into effect.) States have had similar problems when instituting work requirements for other programs, like nutrition assistance.
Work requirements are based on the groundless notion that social programs are rife with abuse. Fraud in these programs is rare, usually committed by health care providers, and rooted out and prosecuted when it occurs. Overall, Americans are much more likely to forgo aid when they need it than commit fraud to try to receive it when they don’t. And supporters and administrators of programs like Medicaid often point to a simple fact that should be obvious: People can’t work, or look for work, if they have unaddressed health problems. They can’t afford enough food. And they don’t have anyone to take care of their children while they’re away from home. Unemployed workers can apply online for jobs or pound the pavement with their resumes in hand, but they can’t force employers to hire them or find jobs that don’t exist. These are the arguments in favor of a social safety net in the first place, and tying them to work would undermine their purpose of being there when people need them most.
The KFF poll did find that support for work requirements dropped when those surveyed heard that most Medicaid recipients already work. But all of these counterarguments took paragraphs to make. Mention things like program design, work requirements, and recertification, and people’s eyes start to glaze over. It is overall a less appealing message than the simple idea presented by Republicans, which is that people should have to work if they’re going to receive government assistance. That’s the challenge Democrats have already faced in attacking the bill, as they highlight the paperwork requirements and funding mechanisms that would result in slashing benefits—while Republicans sneakily claim that they’re not cutting benefits directly.
Democrats don’t believe there should be any work requirements on the program, a position that runs counter to a generation’s worth of Reaganesque messaging Americans have heard about “personal responsibility” and the dignity of work. So Democrats need to broadly reframe the issue and find a simple, repeatable message that cuts through the complications. I don’t pretend to know what that message should be, but it’s clear that those who believe government is a force for good in people’s lives are also at a loss.
