During the Trump administration, the federal government allowed several states to introduce work requirements for people receiving Medicaid—the government program that provides health insurance to low-income individuals and families.
Under these rules, able-bodied adults were required to work, volunteer, or participate in job training (usually around 80 hours per month) to keep their health coverage.
However, federal courts ultimately stepped in and blocked these work requirements. Here is a clear, plain-English breakdown of what happened and why the courts ruled against them.
What Were the Medicaid Work Requirements?
Normally, Medicaid eligibility is based primarily on income. Under the approval of the Trump administration’s Department of Health and Human Services (HHS), states like Arkansas, New Hampshire, and Kentucky were granted special waivers to add work-related rules.
To maintain coverage, beneficiaries had to report their work or community service hours monthly. If they failed to report or didn’t meet the required hours, they would lose their health coverage.
What Did the Courts Rule?
In a series of landmark legal rulings (most notably in Gresham v. Azar), federal courts—including the U.S. District Court for the District of Columbia and the U.S. Court of Appeals for the D.C. Circuit—struck down the administration’s approval of Medicaid work requirements.
Here are the key reasons why the judges ruled against them:
1. The Core Purpose of Medicaid Is Providing Health Coverage
The fundamental legal argument rested on the purpose of the Medicaid Act passed by Congress. The court ruled that the primary objective of Medicaid is to provide medical assistance to low-income people. Because work requirements led directly to tens of thousands of people losing their health coverage, the court held that HHS acted arbitrarily and unlawfully by approving policies that undermined the main goal of the law.
2. Failure to Consider Coverage Loss
Federal law requires government agencies to thoroughly analyze the impact of major policy changes before approving them. The judges noted that the federal government failed to adequately consider how many people would lose their health coverage due to confusion, reporting hurdles, and administrative paperwork, rather than an unwillingness to work.
Example: In Arkansas, where work requirements were temporarily put in place in 2018, more than 18,000 low-income adults lost their Medicaid coverage in just a few months, largely because they struggled to navigate the online reporting system.
What Happened Afterward?
Following the court rulings blocking the policy, the Biden administration officially revoked all remaining federal approvals for Medicaid work requirements in 2021, effectively bringing the program waivers to an end.
Current Status & Debate
While federal courts ruled against executive approvals of work requirements under existing law, the debate continues in Congress. Some lawmakers periodically propose passing new legislation to mandate Medicaid work requirements, but as the law stands today under court precedent, states cannot enforce work requirements under standard administrative waivers that cause beneficiaries to lose coverage.