S-447-119
Read twice and referred to the Committee on Finance.
Sponsored by John Kennedy (R-LA)
What it does
This bill would require most Medicaid enrollees between the ages of 18 and 65 to work or volunteer at least 20 hours per week (averaged monthly) in order to maintain eligibility. Individuals would be exempt if they are unable to work due to a documented medical condition, a qualifying family situation, or another listed reason. Those who do not meet the requirement and do not qualify for an exemption would lose Medicaid coverage.
Who benefits
Taxpayers who favor reduced federal and state Medicaid spending. Employers in low-wage sectors who may see an expanded labor pool if enrollees seek work to maintain coverage. State Medicaid administrators who support work-based eligibility structures. Workers who are already employed and pay into the tax base that funds Medicaid.
Who is hurt
Able-bodied adults currently enrolled in Medicaid who are unemployed or working fewer than 20 hours per week and do not qualify for an exemption — estimates from prior CBO analyses of similar proposals suggest millions could lose coverage. Individuals in informal caregiving roles (e.g., caring for a sick relative) who may struggle to document exemptions. Part-time or gig economy workers whose hours fluctuate month to month and may fall below the threshold intermittently. Safety-net hospitals and community health centers that serve uninsured patients, who may face increased uncompensated care costs if enrollment drops. Rural residents in areas with limited job opportunities. State Medicaid agencies, which would bear significant administrative costs to verify compliance.
Supporters argue
Supporters argue that Medicaid was designed as a temporary support for vulnerable populations, not a permanent benefit for working-age adults who are capable of employment, and that work requirements encourage self-sufficiency and long-term economic mobility. They contend that Arkansas's 2018 work requirement pilot — before it was halted by courts — showed that a meaningful share of enrollees were already working or quickly found work, suggesting the requirement can be met without widespread coverage loss for those genuinely able to work. Supporters further argue that linking benefits to participation mirrors requirements in other federal assistance programs such as SNAP and TANF, creating a consistent standard across the safety net.
Opponents argue
Opponents argue that research on Arkansas's 2018 work requirement — the only large-scale U.S. test — found that over 18,000 people lost coverage within months, with no measurable increase in employment, because most enrollees who lost coverage were already working, were exempt, or faced bureaucratic barriers to proving compliance. They contend that the administrative burden of monthly verification falls disproportionately on people with unstable jobs, limited internet access, or literacy challenges, causing coverage losses unrelated to actual work status. Opponents further argue that losing health coverage can itself be a barrier to employment, as untreated illness reduces workforce participation — undermining the bill's stated goal.
Constitutional context
Medicaid is a federal-state cooperative program funded under the Taxing and Spending Clause (Art. I, §8, cl. 1). In NFIB v. Sebelius (2012), the Supreme Court held that Spending Clause conditions on states must not be so coercive as to leave states no genuine choice; however, this bill imposes conditions on individual enrollees, not states, which raises a distinct legal question about the scope of federal authority to define eligibility criteria within an existing program.
Checks and balances
Congress would gain authority to define new eligibility conditions for Medicaid; the executive branch (HHS) would implement and enforce verification rules; federal courts would retain authority to review whether the conditions exceed statutory or constitutional limits, as they did when blocking Arkansas's 2018 pilot.
Historical precedent
Arkansas implemented a Medicaid work requirement in 2018 under a federal waiver, but federal courts struck it down in 2019, holding that HHS had not adequately considered the impact on coverage — the only large-scale U.S. test of this policy to date.