Document Type


Publication Date


Publication Information

27 Annals of Health Law 37 (2018)


Many health policy scholars believe that Medicaid, the federal-state coverage program for lower-income Americans, should remain free from welfare reform trappings such as work requirements that are extraneous to the program. It would seem such requirements would be both inappropriate and counterproductive to the goals of Medicaid. Given the high probability that such requirements will, at least at some level, go into effect during the Trump administration, it bears considering what to expect. What evidence, if any, suggests that imposing welfare reform-style requirements on certain Medicaid beneficiaries will yield harmful results to those beneficiaries, or harmful to Medicaid’s programmatic goal of ensuring health care access to lower-income Americans?

While one might expect the last two decades to have yielded clear and substantial evidence of the consequences of state-implemented work requirements in the Temporary Aid for Needy Families (TANF) program, this is not quite the case. Inadequate collection of data, large loopholes, and some states’ widely differing implementation policies at the county level muddy a definitive determination of the impact that individual reforms such as work requirements had on TANF take-up and retention, let alone any applicability such data might have to Medicaid. That being said, existing data suggests that such requirements in TANF are associated with reduced cash welfare uptake and retention and reduced provision of cash benefits. The data from TANF would be more useful if the program were implemented uniformly across each state, and if the effects of state policy choices on beneficiary take-up, retention, and outcomes were tracked through careful data collection and analysis. If welfare reform requirements are imposed in Medicaid, CMS should insist on uniform program implementation and thorough, well-considered collection of data to better study their effects.