On Friday, December 4th, the Supreme Court announced plans to review the legal basis of mandatory work requirements for Medicaid participants. While work requirements for welfare programs were introduced in the 1990s under the Clinton Administration’s push to “end welfare as we know it,” controversy exists over imposing such conditions in exchange for healthcare coverage and security.

Last year, over 75 million people enrolled in Medicaid, a federal program that provides free or low-cost health insurance to vulnerable populations. While primarily funded by the federal government, states also contribute funds. In addition, each state is given some autonomy in the operation and distribution of coverage with the stipulation that certain conditions are met. Therefore, access to Medicaid varies significantly from state to state.

States can also apply for waivers to essentially opt-out of Medicaid’s minimum coverage requirements with the intent of creating experimental projects. Waivers require approval by the Department of Health and Human Services (HHS), and approval is granted to such pilot programs if the objectives align with Medicaid’s primary mission.

Currently, the Department of Health and Human Services has approved eight states to impose work requirements. While not in effect due to the federal government’s freeze on relinquishing Medicaid benefits during COVID-19, the Kaiser Family Foundation estimates that 4.1 million people could potentially lose coverage following the establishment of work conditions.

The Trump Administration has mobilized states to impose work requirements with the goal of incentivizing individuals “to engage in their own health care and achieve better health outcomes.” Under Section 1115 of the Social Security Act, HHS has encouraged states to file waivers to create new demonstration projects.

In 2017, with the Trump Administration’s approval, Arkansas created a program called “Arkansas Works,” in which Medicaid beneficiaries were required to work or attend training for at least 80 hours per month. During the first five months, more than 18,000 people lost their Medicaid coverage.

Lower federal courts have ruled against such requirements. The United States Court of Appeals for the District of Columbia Circuit ruled unanimously that work stipulations for Medicaid beneficiaries do not align with the overall objectives of Medicaid. In addition, it was noted that the administration failed to take into account the large number of people who would lose health coverage as a result of establishing work requirements.

While it is likely that the Supreme Court review will not take place until after Inauguration Day, many Medicaid participants may be in jeopardy. Exacerbated by the effects of a global pandemic, the decision of the Supreme Court could greatly impact the security of many vulnerable populations.