Conditioning Access to Programs that Ensure a Basic Foundation for
Families on Work Requirements
Unworkable & Unwise:
KALI GRANT, FUNKE ADERONMU,
SOPHIE KHAN, KAUSTUBH CHAHANDE,
CASEY GOLDVALE, INDIVAR DUTTA-GUPTA,
AILEEN CARR, & DOUG STEIGER
REVISED FEBRUARY 1, 2019
WORKING PAPER
Copyright
Creative Commons (cc) 2019 by Kali Grant, Funke Aderonmu, Sophie Khan, Kaustubh
Chahande, Casey Goldvale, Indivar Dutta-Gupta, Aileen Carr, & Doug Steiger.
Notice of rights: This report has been published under a Creative Commons license. This
work may be copied, redistributed, or displayed by anyone, provided that proper
attribution is given and that the adaptation also carries a Creative Commons license.
Commercial use of this work is disallowed.
Georgetown Center on Poverty and Inequality
The Georgetown Center on Poverty and Inequality (GCPI) works with
policymakers, researchers, practitioners, advocates, and people with lived
experience to develop effective policies and practices that alleviate poverty
and inequality in the United States.
GCPI conducts research and analysis, develops policy and programmatic
solutions, hosts convenings and events, and produces reports, briefs, and
policy proposals. We develop and advance promising ideas and identify risks
and harms of ineffective policies and practices, with a cross-cutting focus on
racial and gender equity.
The work of GCPI is conducted by two teams: the Initiative on Gender Justice
and Opportunity and the Economic Security and Opportunity Initiative.
Economic Security and Opportunity Initiative at GCPI
The mission of GCPI’s Economic Security and Opportunity Initiative
(ESOI) is to expand economic inclusion in the United States through
rigorous research, analysis, and ambitious ideas to improve
programs and policies. Further information about GCPI’s ESOI is
available at www.georgetownpoverty.org.
Please refer any questions or comments to
[email protected].
Working Paper
Unworkable & Unwise | 3
Acknowledgements & Disclosures
We appreciate the generous assistance provided by the following individuals,
who shared their insights and advice, some of whom reviewed drafts of this
report: Elizabeth Lower-Basch, Elayne Weiss, Ellen Vollinger, Elisa Minoff, Kate
Bahn, LaDonna Pavetti, Kelly Whitener, Rachel Black, and TJ Sutcliffe. We also
thank those who attended the convening on these issues on September 7, 2018
for their insights and expertise.
We thank Isabella Camacho-Craft and Cara Brumfield for significant research,
writing, and editing assistance, and Danny Vinik for assistance with citations.
Any errors of fact or interpretation remain the authors’.
We are grateful to the Annie E. Casey Foundation for its support for our
research and analysis of work requirements and the JPB Foundation for its
support of our cross-cutting idea development and other work. The views
expressed are those of the GCPI ESOI authors and should not be attributed to
our advisors or funders. Funders do not affect research findings or the insights
and recommendations of GCPI’s ESOI.
Contents
Acknowledgements & Disclosures ......................................................................................................3
Contents ............................................................................................................................................4
Abbreviations, Acronyms, & Initializations ..........................................................................................7
Executive Summary ............................................................................................................................8
Medicaid, SNAP, & Housing Assistance Ensure a Foundation for Families............................................... 8
Removing Access to Health Care, Food, & Housing Assistance Is Counterproductive ........................... 11
Key Findings ............................................................................................................................................. 13
Policy Recommendations ........................................................................................................................ 14
Introduction .................................................................................................................................... 16
Medicaid, SNAP, & Housing Assistance Ensure a Foundation for Families............................................. 16
Removing Access to Health Care, Food, & Housing Assistance Is Counterproductive ........................... 17
Taking Assistance Away From Participants Who Do Not Meet Work Requirements is Ill-Informed...... 19
Our Economic Security System is Already Heavily Tied to Formal Employment .................................... 19
Nearly All Program Participants Have Worked, Still Work, & Will Work in the Future—or Face Major
Barriers to Work, Due to Factors Such as Age or Disability .................................................................... 21
Participants Face Barriers to Employment That Work Requirements Ignore ......................................... 22
Medicaid, SNAP, & Housing Assistance Support Work ........................................................................... 28
Medicaid Supports Work .................................................................................................................... 28
SNAP Supports Work ........................................................................................................................... 29
Housing Assistance Supports Work .................................................................................................... 29
Medicaid, Snap, & Housing Assistance Improve Labor Market Outcomes for the Next Generation 30
The Details of Harsh Work Requirement Proposals Make Little Sense for Low-Paid Workers .............. 31
Low-Wage Employers Routlinely Provide Uneven & Insufficient Work Hours .................................. 32
Low-Paid Workers Have Limited Control over Their Work Hours ...................................................... 32
Punitive, Inflexible Rules Are Poorly Aligned with the Low-Wage Labor Market .............................. 33
New Rules Can Make Medicaid Access Impossible for Some ............................................................. 33
Taking Benefits Away from People Who Do Not Meet a Work Requirement is Ineffective .................. 34
Removing People Unable to Meet a Work Requirement from Vital, Work-Supporting Programs Has
Limited Effects on Employment .............................................................................................................. 34
Available Evidence Suggests That Few Will Benefit, but Many Will Lose Needed Supports ............. 34
Increasing Employment & Incomes Requires Resources & Strategies Not Provided by Work
Requirements ...................................................................................................................................... 35
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Work Requirements Fail to Reduce Poverty & May Even Increase Poverty by Weakening Foundational
Programs ................................................................................................................................................. 37
Deep Poverty is Likely to Rise as a Result of Work Requirements Weakening Foundational Programs 37
Work Requirements Lack Important Guardrails for States & Undermine Already-Effective Programs . 39
Revoking Access to Work-Supporting Programs Due to Rigid & Impractical Work Requirements is
Inefficient ........................................................................................................................................ 41
States Make it Difficult to Comply with Work Requirements ................................................................. 41
Work Rules Impose Cumbersome Requirements on Participants, Regardless of Employment Status
............................................................................................................................................................. 41
Participants Bear the Burden of Navigating Unreliable & Uneven Exemption Processes ................. 43
Work Requirements Are Burdensome for States & Their Limited Resources ........................................ 45
States Are Ill-Equipped to Administer Work Requirements ............................................................... 46
Proposals That Take Benefits Away from People Who Do Not Meet a Work Requirement May
Increase Costs for States ..................................................................................................................... 47
Work Requirements Fail to Consider Macroeconomic Ramifications for States ............................... 48
Policies to Take Benefits Away from Recipients Who Do Not Meet a Work Requirement Are
Inequitable ...................................................................................................................................... 51
Work Requirements Disparately Harm Groups Who Experience Systemic Oppression ........................ 51
People Living with Disabilities & Chronic Health Conditions .............................................................. 51
People of Color .................................................................................................................................... 52
Women ................................................................................................................................................ 54
LGBTQ Individuals ............................................................................................................................... 54
Older Adults ........................................................................................................................................ 55
Other Groups Experiencing Deep Economic Insecurity Will be Disparately Harmed by Work
Requirements .......................................................................................................................................... 55
Low-Income Caregivers & Their Families ............................................................................................ 55
People with Criminal Justice System Involvement ............................................................................. 56
Former Foster Youth ........................................................................................................................... 56
Victim-Survivors of DV/IPV, Trauma, & Violence ............................................................................... 57
Veterans with Disabilities.................................................................................................................... 57
Work Requirements Are Likely to Harm People, Families, & Communities Struggling the Most .......... 57
Damage To Well-Being of Families & Children ................................................................................... 58
Increase In Economic Insecurity & Hardship ...................................................................................... 59
Health Outcomes Likely to Worsen .................................................................................................... 59
Fewer Federal Resources Flowing into Left-Behind Communities ..................................................... 60
An Agenda to Increase Employment & Earnings Would Look Very Different ...................................... 62
Ensure a Foundation for Individuals & Families ...................................................................................... 62
Ensure Access to Work Supports like Medicaid, SNAP, & Housing, Including Expanding Medicaid in
All States .............................................................................................................................................. 62
Strengthen TANF ................................................................................................................................. 63
Raise the Minimum Wage (Including for Tipped Workers & People with Disabilities) ...................... 63
Strengthen Family Stability ..................................................................................................................... 64
Reform Unemployment Insurance & Establish a Jobseeker’s Allowance .......................................... 64
Ensure Access to Quality, Decent Jobs & Fair Labor Standards.......................................................... 65
Reform the Criminal Justice System ................................................................................................... 65
Support Workers ..................................................................................................................................... 66
Expand Proven Workforce Development Funding & Reach ............................................................... 66
Develop Subsidized & Public Employment Programs to Address Barriers to Employment, Including
Place-Based Disparities ....................................................................................................................... 67
Expand Child Care Assistance ............................................................................................................. 67
Expand the Earned Income Tax Credit (EITC) ..................................................................................... 68
Conclusion ....................................................................................................................................... 69
Appendices ...................................................................................................................................... 70
Appendix A. Medicaid ............................................................................................................................. 70
Summary of Medicaid Waivers Permitting State Work Requirements .............................................. 70
Summary of Approved Medicaid Work Requirement Policies ........................................................... 73
Appendix B. SNAP .................................................................................................................................... 78
Existing SNAP Work Requirements ..................................................................................................... 78
2018 House Republican Farm Bill SNAP Work Requirement Proposal............................................... 78
The Trump Administration’s Proposed Rule on Time Limits .............................................................. 79
Appendix C. Housing................................................................................................................................ 81
Trump Administration FY2018 Budget Proposal ................................................................................ 81
Trump Administration FY2019 Budget Proposal ................................................................................ 82
Making Affordable Housing Work Act of 2018 ................................................................................... 82
Fostering Stable Housing Opportunities Act of 2018 ......................................................................... 82
HUD Moving-To-Work Demonstrations.............................................................................................. 83
HUD Public Housing Community Service and Self-Sufficiency Requirement ..................................... 83
Endnotes ......................................................................................................................................... 84
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Unworkable & Unwise | 7
Abbreviations, Acronyms, & Initializations
ABAWDs—Able-Bodied Adults without
Dependents
ACA—Affordable Care Act (Patient Protection
and Affordable Care Act)
AFDC—Aid to Families with Dependent Children
AIAN—American Indians and Alaska Natives
CCDBG—Child Care and Development Block
Grant
CCDF—Child Care and Development Fund
CDC—Centers for Disease Control and
Prevention
CEA—Council of Economic Advisers
CMS—Centers for Medicare and Medicaid
Services
HHS—U.S. Department of Health and Human
Services
DV/IPV—Domestic Violence/Intimate Partner
Violence
EITC—Earned Income Tax Credit
EPSDT—Early Periodic Screening, Diagnostic
and Treatment
FY—Fiscal Year
GA—General Assistance
GAO—U.S. Government Accountability Office
HUD—U.S. Department of Housing and Urban
Development
IHS—Indian Health Service
Jobseeker’s Allowance—JSA
LGBTQ—Lesbian, Gay, Bisexual, Transgender,
Queer
MTW—Moving to Work Demonstration
PHA—Public Housing Authority
SNAP—Supplemental Nutrition Assistance
Program
SSBG—Social Services Block Grant
SSDI—Social Security Disability Insurance
SSI—Supplemental Security Income
TANF—Temporary Assistance for Needy
Families
UI—Unemployment Insurance
USDA—U.S. Department of Agriculture
WIOA—Workforce Innovation and Opportunity
Act
Executive Summary
n recent years, the Trump Administration, members of Congress, governors, and state legislatures
have put forward, and in some cases implemented, new and harsher proposals to take away health
care, food, and housing assistance from people who do not meet a work requirement. The programs
being targeted for new work requirements—Medicaid, Supplemental Nutrition Assistance Program
(SNAP), and housing assistance—are lifelines for individuals and families during times without sufficient
work or earnings. Because these proposals reflect misunderstandings of these programs and
participants, they are or will be harmful to the well-being of people with low incomes. These policies
differ substantially from program to program and state to state, and variations are likely to continue to
appear. Regardless, the policies all suffer from the same flaws inherent in conditioning foundational
support on documenting and participating in approved activities. As a result, this report focuses on
these policies generally rather than on any particular one (though some key policies are described in the
Appendix). In addition, alongside proposed restrictions for immigrants’ access to,
i
budget cuts for,
ii
and
the ending of other participant protections in economic security programs,
iii
these new work rules are
part of a broader strategy of gatekeeping, shrinking, and undermining the system of supports for
struggling individuals and families.
iv
The connection to other proposals, often proposed with similar
rationales and based on similar misunderstandings of programs and participants, suggests a need to
detail the sizeable body of evidence of the effectiveness of Medicaid, SNAP, and housing assistance in
supporting people with low incomes as they overcome challenges they face.
Medicaid, SNAP, & Housing Assistance Ensure a Foundation for Families
Research on the effects of economic security programs strongly suggests that every individual and every
family require a stable and strong foundation to be healthy and succeed in the labor market and
i
Fremstad, Shawn. “Trump’s ‘Public Charge’ Rule Would Radically Change Legal Immigration.” Center for American
Progress, 27 November 2018. Available at
https://www.americanprogress.org/issues/poverty/reports/2018/11/27/461461/trumps-public-charge-rule-
radically-change-legal-immigration/.
ii
Parrott, Sharon et al. “Trump Budget Deeply Cuts Health, Housing, Other Assistance for Low- and Moderate-
Income Families.” Center on Budget and Policy Priorities, 14 February 2018. Available at
https://www.cbpp.org/research/federal-budget/trump-budget-deeply-cuts-health-housing-other-assistance-for-
low-and.
iii
These proposals include turning Medicaid into a block grant and efforts to move HUD away from its focus on
housing discrimination. See: “Trump Administration Plans Effort to Let States Remodel Medicaid.” Wall Street
Journal, 11 January 2019. Available at https://www.wsj.com/articles/trump-administration-plans-effort-to-let-
states-remodel-medicaid-11547259197 and “Ben Carson is Pulling HUD Away From its Key Mission.” Vox, 11 April
2018. Available at https://www.vox.com/identities/2018/3/8/17093136/ben-carson-hud-discrimination-fair-
housing-anniversary.
iv
See for example the discussion of cuts, work requirements, and restructuring of economic security programs
here: Golden, Olivia. “Moving America’s Families Forward: Setting Priorities for Reducing Poverty and Expanding
Opportunity.” Testimony presented to the Committee on Ways and Means, U.S. House of Representatives, 24 May
2016. Available at https://www.clasp.org/sites/default/files/public/resources-and-publications/publication-
1/2016-05-24-Olivia-Golden-Testimony-to-House-Ways-and-Means.pdf.
I
Working Paper
Unworkable & Unwise | 9
beyond.
v
,
vi
,
vii
,
viii
That foundation, especially for people struggling in the labor market, is often ensured
through public benefits and services, including Medicaid, SNAP, and housing assistance. These programs
have demonstrated beneficial long-term, intergenerational effects on employment and earnings for the
children in families who participate.
ix
,
x
,
xi
,
xii
By providing economic security for disadvantaged individuals
and families, Medicaid, SNAP, and housing assistance also advance economic opportunity.
Medicaid, SNAP, and housing assistance programs provide essential services and support to tens of
millions of individuals and families in the United States. In 2010, Medicaid kept at least 2.6 to 3.4 million
people out of poverty.
xiii
In 2017, SNAP and housing subsidies kept 3.4 million and 2.9 million people out
of poverty, respectively (all by the Supplemental Poverty Measure, or SPM).
xiv
Medicaid is a federal-state
partnership that provides health coverage for more than 1 in 5 people in the United States, including
v
Hoynes, Hilary, Diane Whitmore Schanzenbach, and Douglas Almond. "Long-Run Impacts of Childhood Access to
the Safety Net." American Economic Review, April 2016. Available at
https://gspp.berkeley.edu/assets/uploads/research/pdf/Hoynes-Schanzenbach-Almond-AER-2016.pdf.
vi
Bivens, Josh, and Shawn Fremstad. "Why Punitive Work-Hours Tests in SNAP and Medicaid Would Harm Workers
and Do Nothing to Raise Employment." Economic Policy Institute, 26 July 2018. Available at
https://www.epi.org/publication/why-punitive-work-hours-tests-in-snap-and-medicaid-would-harm-workers-and-
do-nothing-to-raise-employment/.
vii
Sherman, Arloc, and Tazra Mitchell. "Economic Security Programs Help Low-Income Children Succeed Over Long
Term, Many Studies Find." Center on Budget and Policy Priorities, 17 July 2017. Available at
https://www.cbpp.org/research/poverty-and-inequality/economic-security-programs-help-low-income-children-
succeed-over.
viii
Carlson, Steven, and Zoe Neuberger. "WIC Works: Addressing the Nutrition and Health Needs of Low-Income
Families for 40 Years." Center on Budget and Policy Priorities, updated 29 March 2017. Available at
https://www.cbpp.org/research/food-assistance/wic-works-addressing-the-nutrition-and-health-needs-of-low-
income-families.
ix
Hoynes, Hilary, Diane Whitmore Schanzenbach, and Douglas Almond. "Long-Run Impacts of Childhood Access to
the Safety Net." American Economic Review, April 2016. Available at
https://gspp.berkeley.edu/assets/uploads/research/pdf/Hoynes-Schanzenbach-Almond-AER-2016.pdf.
x
Sherman, Arloc, and Tazra Mitchell. "Economic Security Programs Help Low-Income Children Succeed Over Long
Term, Many Studies Find." Center on Budget and Policy Priorities, 17 July 2017. Available at
https://www.cbpp.org/research/poverty-and-inequality/economic-security-programs-help-low-income-children-
succeed-over.
xi
Brown, David W., Amanda E. Kowalski, and Ithai Z. Lurie. "Medicaid as an Investment in Children: What is the
Long-Term Impact on Tax Receipts?" NBER Working Paper No. 20835, January 2015. Available at
https://www.nber.org/papers/w20835.pdf.
xii
Chetty, Raj, Nathaniel Hendren, and Lawrence F. Katz. "The Effects of Exposure to Better Neighborhoods on
Children: New Evidence from the Moving to Opportunity Project." American Economic Review 106(4): 855-902,
August 2015. Available at https://pubs.aeaweb.org/doi/pdfplus/10.1257/aer.20150572.
xiii
Sommers, Benjamin D., and Donald Oellerich. "The poverty-reducing effect of Medicaid." Journal of Health
Economics, 32(5): 816-832, September 2013. Available at
https://www.sciencedirect.com/science/article/pii/S016762961300091X.
xiv
Fox, Liana. "The Supplemental Poverty Measure: 2016." U.S. Census Bureau, revised September 2017. Available
at https://www.census.gov/content/dam/Census/library/publications/2017/demo/p60-261.pdf.
millions of low-wage workers and their families
xv
and people in need of long-term support and
services.
xvi
Medicaid provides vital health care coverage to many who would otherwise lack it. SNAP is
state-administered and largely federally-funded, helping approximately 1 in 8 people in the U.S.
xvii
purchase food—including many who are at greatest risk of experiencing hunger or poor nutrition.
xviii
Federally-funded housing assistance provides rental aid for some households with the lowest incomes
and is generally administered through local housing authorities, who in turn provide vouchers, directly
subsidize units in private housing developments, or build and maintain public housing
xix
for fewer than 1
in 30 people in the U.S.
xx
Particularly in light of the decline of Temporary Assistance for Needy Families
(TANF)
xxi
and General Assistance (GA),
xxii
which provide cash assistance to families and individuals
respectively, and the challenges of today’s low-wage labor market, these programs are essential for
ensuring that people do not fall below a floor for material deprivation or economic resources.
xxiii
xv
Garfield, Rachel, Robin Rudowitz, and Anthony Damico. “Understanding the Intersection of Medicaid and Work.”
Kaiser Family Foundation, 5 January 2018. Available at https://www.kff.org/medicaid/issue-brief/understanding-
the-intersection-of-medicaid-and-work/.
xvi
Rudowitz, Robin, and Rachel Garfield. "10 Things to Know about Medicaid: Setting the Facts Straight." Kaiser
Family Foundation, 12 April 2018. Available at https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-
medicaid-setting-the-facts-straight/.
xvii
"Supplemental Nutrition Assistance Program Participation and Costs." Food and Nutrition Service, U.S.
Department of Agriculture, 7 December 2018. Available at https://fns-
prod.azureedge.net/sites/default/files/pd/SNAPsummary.pdf.
xviii
Kearney, Melissa S., and Benjamin H. Harris. "Hunger and the Important Role of SNAP as Part of the American
Safety Net." Brookings Institute, 22 November 2013. Available at https://www.brookings.edu/blog/up-
front/2013/11/22/hunger-and-the-important-role-of-snap-as-part-of-the-american-safety-net/.
xix
"Policy Basics: Federal Rental Assistance." Center on Budget and Policy Priorities, updated 15 November 2017.
Available at https://www.cbpp.org/research/housing/policy-basics-federal-rental-assistance.
xx
Authors’ calculation using data at "Assisted Housing: National and Local." Office of Policy Development and
Research, U.S. Department of Housing and Urban Development, retrieved 17 December 2018. Available at
https://www.huduser.gov/portal/datasets/assthsg.html#2009-2017_query; "Section 521 Rental Assistance:
Households Members." U.S. Department of Agriculture, 6 April 2018. Available at
https://www.rd.usda.gov/files/RDUL-MFHannual.pdf; "U.S. and World Population Clock." U.S. Census Bureau,
updated 25 January 2019. Available at https://www.census.gov/popclock/.
xxi
Dutta-Gupta, Indi, and Kali Grant. “TANF’s Not All Right.” The Hill, 30 April 2015. Available at
https://thehill.com/opinion/op-ed/240666-tanfs-not-all-right.
xxii
“In recent decades, a number of states have eliminated their General Assistance programs, while many others
have cut funding, restricted eligibility, imposed time limits, and/or cut benefits.” See: Schott, Liz, and Misha Hill.
“State General Assistance Programs Are Weakening Despite Increasing Need.” Center for Budget and Policy
Priorities, 9 July 2015. Available at https://www.cbpp.org/research/family-income-support/state-general-
assistance-programs-are-weakening-despite-increased.
xxiii
Shaefer, H. Luke, et al. "The Decline of Cash Assistance and the Well-Being of Households with Children."
Poverty Solutions at the University of Michigan, 28 August 2018. Available at https://poverty.umich.edu/working-
paper/the-decline-of-cash-assistance-and-the-well-being-of-households-with-children/.
Working Paper
Unworkable & Unwise | 11
Removing Access to Health Care, Food, & Housing Assistance Is
Counterproductive
Work requirements in programs ensuring a basic foundation for people have a long history of poor
outcomes, though recent proposals are unprecedented. New work requirements are inspired in part by
similar policies imposed on TANF recipients since 1996 that likely have contributed to increases in deep
poverty, as detailed later in this report.
SNAP and housing assistance programs have had some requirements related to work activities for some
participants in the past, but the proposals discussed in this paper would make them harsher and include
a far larger share of participants. At the federal level, longstanding SNAP time limits have substantially
limited access for many unemployed and underemployed adults, though states have routinely applied
for and received waivers from these draconian provisions.
xxiv
In 2016, about half a million participants
lost food assistance because they failed to meet a SNAP work time limit.
xxv
Recent proposals would
make these SNAP rules harsher still.
xxvi
Federally-funded housing assistance programs have
experimented with requirements related to work activities through demonstrations, but never as a part
of widely-applicable policy.
xxvii
(For the purposes of this paper, “housing assistance programs” refer to
Section 8 Housing Choice Vouchers, Public Housing, and Project-Based Rental Assistance programs.)
Until now, Medicaid had never been tied to formal employment; its central purpose is to provide health
coverage to people with very low incomes. Removing participants and leaving them uninsured due to
not meeting or documenting work or community engagement activities is thus new to Medicaid. As of
January 2019, 16 states have applied for, and one has implemented, work requirements in Medicaid;
this number is expected to grow.
xxviii
(The legal question of whether applying such requirements through
Medicaid state waivers is consistent with the program’s purpose of providing medical care and
treatment is the subject of ongoing litigation, as discussed in the Appendix.)
xxix
Efforts to take benefits away from many more participants in Medicaid, SNAP, or housing assistance
programs misunderstand the populations such programs aim to serve and grossly underestimate the
xxiv
Bolen, Ed, and Stacy Dean. “Waivers Add Key State Flexibility to SNAP’s Three-Month Time Limit.” Center for
Budget and Policy Priorities, 6 February 2018. Available at https://www.cbpp.org/research/food-
assistance/waivers-add-key-state-flexibility-to-snaps-three-month-time-limit.
xxv
Bolen, et al. “More than 500,000 Adults Will Lose SNAP Benefits in 2016 as Waivers Expire.” 2016.
xxvi
Paquette, Danielle, and Jeff Stein. "Trump Administration Aims to Toughen Work Requirements for Food Stamp
Recipients." Washington Post, 20 December 2018. Available at
https://www.washingtonpost.com/business/economy/trump-administration-aims-to-toughen-work-
requirements-for-food-stamps-recipients/2018/12/20/cf687136-03e6-11e9-b6a9-
0aa5c2fcc9e4_story.html?noredirect=on.
xxvii
Jan, Tracy. "Trump Wants More People Who Receive Housing Subsidies to Work." Washington Post, 23 May
2017. Available at https://www.washingtonpost.com/news/wonk/wp/2017/05/23/for-the-first-time-poor-people-
receiving-housing-subsidies-may-be-required-to-work/?noredirect=on&utm_term=.a98e8b97d80f.
xxviii
“State Waivers List.” Medicaid.gov, Retrieved 15 January 2019. Available at
https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/index.html.
xxix
Rosenbaum, Sara. “Stewart v. Azar and the Future of Medicaid Work Requirements.” Commonwealth Fund, 3
July 2018. Available at https://www.commonwealthfund.org/future-of-Medicaid-work-requirements.
harm to families and individuals as a result of these policies. The new policies also ignore the structural
barriers people with very low incomes face, including the unavailability of full-time work and the
instability of low-wage jobs today.
xxx
Alongside a 3.9 percent December 2018 unemployment rate, 7.6
percent
xxxi
(12.8 million people)
xxxii
of the civilian labor force plus marginally-attached
xxxiii
workers was
unemployed or underemployed.
xxxiv
At the same time, many communities of color continue to face
recession-like circumstances despite a lengthy period of economic growth for the U.S. For example, the
December 2018 unemployment rate for African Americans was 6.6 percent
xxxv
—a figure that, as a
statewide unemployment rate, could be high enough to trigger permanent law Extended Benefits under
the Unemployment Insurance (UI) program.
xxxvi
This high African American unemployment rate comes
more than 114 months into an economic expansion, the second longest in U.S. recorded economic
history.
xxxvii
These indicators reveal a strong desire for greater employment than offered or available in
what otherwise may seem to some to be a full-employment labor market.
As a result, low-paid workers, people of color,
xxxviii
people with disabilities or chronic health conditions
(including mental health conditions and substance use disorders),
xxxix
people with criminal records,
xl
and
xxx
Hahn, Heather. “Work Requirements in Safety Net Programs: Lessons for Medicaid from TANF and SNAP.”
Urban Institute, April 2018. Available at
https://www.urban.org/sites/default/files/publication/98086/work_requirements_in_safety_net_programs_0.pdf.
xxxi
Author’s calculations. See: “Databases, Tables and Calculators by Subject.” Bureau of Labor Statistics, U.S.
Department of Labor, retrieved 26 January 2019. Available at https://data.bls.gov/timeseries/LNS13327709.
xxxii
“Labor Force Statistics from the Current Population Survey.” Bureau of Labor Statistics, U.S. Department of
Labor, updated 4 January 2019. Available at https://www.bls.gov/web/empsit/cpseea03.htm.
xxxiii
“BLS Information: Glossary.” Bureau of Labor Statistics, U.S. Department of Labor, updated 7 June 2016.
Available at https://www.bls.gov/bls/glossary.htm.
xxxiv
These workers were either unemployed; employed part-time for economic reasons; or were available for work,
had looked for a job sometime in the prior 12 months (or since the end of their last job if they held one within the
past 12 months), but were not counted as unemployed because they had not searched for work in the prior 4
weeks.
xxxv
“Unemployment Rate: Black or African American (LNS14000006).” Federal Reserve Bank of St. Louis and Bureau
of Labor Statistics, U.S. Department of Labor, retrieved 26 January 2019. Available at
https://fred.stlouisfed.org/series/LNS14000006.
xxxvi
Whittaker, Julie M., and Katelin P. Isaacs. “Unemployment Insurance: Programs and Benefits.” Congressional
Research Service, 27 February 2018. Available at https://crsreports.congress.gov/product/pdf/RL/RL33362.
xxxvii
“US Business Cycle Expansions and Contractions.” National Bureau of Economic Research (NBER), retrieved 26
January 2019. Available at https://www.nber.org/cycles/cyclesmain.html.
xxxviii
Hahn, Heather, et al. “Why Does Cash Welfare Depend on Where You Live? How and Why State TANF
Programs Vary.” Urban Institute, 5 June 2017. Available at https://www.urban.org/research/publication/why-
does-cash-welfare-depend-where-you-live.
xxxix
Ku, Leighton, and Erin Brantley. “Medicaid Work Requirements: Who’s at Risk?" Health Affairs, 12 April, 2017.
Available at https://www.healthaffairs.org/do/10.1377/hblog20170412.059575/full/.
xl
Wolkomir, Elizabeth. “How SNAP Can Better Serve the Formerly Incarcerated.” Center on Budget and Policy
Priorities, 16 March 2018. Available at https://www.cbpp.org/research/food-assistance/how-snap-can-better-
serve-the-formerly-incarcerated.
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Unworkable & Unwise | 13
children
xli
will be harmed, rather than helped, by proposals that take food, health care, and housing
assistance away if recipients do not satisfy work requirements. These programs support and promote
work, not just for adult participants but for their children when they become adults.
xlii
Key Findings
Taking away health coverage, food, and housing support from people who are unable to either
document work-related activities, work, or find work will cause more harm than good. Many people
who are or will be affected by such requirements are already participating in the labor force, meeting
family and caregiving responsibilities, or have other serious or multiple barriers to employment.
xliii
Establishing or expanding harsh penalties (or sanctions) in programs that help ensure a basic foundation
for families promises few benefits and poses substantial costs to already-struggling people.
xliv
,
xlv
In this
report, we examine how the newly-proposed “work requirements” in Medicaid, SNAP, and housing
assistance are ill-informed, ineffective, inefficient, and inequitable, and how alternative policies would
produce outcomes that reduce poverty and increase opportunity:
• Ill-Informed. Weakening foundational programs by taking benefits away from people who do
not meet harsh work requirements ignores the realities of today’s low-wage labor market and
the systemic barriers—such as caregiving responsibilities and discrimination—standing between
people and quality, stable, and secure employment. At the same time, the majority of working-
age program participants without a work-limiting disability generally work.
xlvi
• Ineffective. Though they should be strengthened, the affected economic security programs are
designed to and already do support and enable work. Mandatory work requirements, on the
xli
“Taking Away Medicaid for Not Meeting Work Requirements Harms Children.” Center on Budget and Policy
Priorities, updated 20 December 2018. Available at https://www.cbpp.org/research/health/harm-to-children-
from-taking-away-medicaid-from-people-for-not-meeting-work.
xlii
Page, Marianne. "Safety Net Programs Have Long-term Benefits for Children in Poor Households." Center for
Poverty Research, University of California, Davis, March 2017. Available at
https://poverty.ucdavis.edu/sites/main/files/file-attachments/cpr-health_and_nutrition_program_brief-
page_0.pdf.
xliii
Bauer, Lauren, Diane Whitmore Schanzenbach, and Jay Shambaugh. "Work Requirements and Safety Net
Programs." Hamilton Project, October 2018. Available at https://www.brookings.edu/wp-
content/uploads/2018/10/WorkRequirements_EA_web_1010_2.pdf.
xliv
Pavetti, LaDonna. "TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work." Center on Budget and Policy Priorities, 13 November 2018. Available at
https://www.cbpp.org/research/family-income-support/tanf-studies-show-work-requirement-proposals-for-other-
programs-would.
xlv
Ku, Leighton, et al. “Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve
Health?” The Commonwealth Fund, 6 November 2018. Available at
https://www.commonwealthfund.org/publications/issue-briefs/2018/nov/medicaid-work-requirements-will-they-
help-jobs-health.
xlvi
Bauer, Lauren, Diane Whitmore Schanzenbach, and Jay Shambaugh. "Work Requirements and Safety Net
Programs." Hamilton Project, October 2018. Available at https://www.brookings.edu/wp-
content/uploads/2018/10/WorkRequirements_EA_web_1010_2.pdf.
other hand, are generally ineffective at achieving their goal of reducing poverty through greater
employment and earnings.
xlvii
In fact, they likely will result in the deepening or increasing of
poverty
xlviii
and compound existing challenges with an already overburdened, underfunded
workforce system.
xlix
Because states fail to communicate effectively about how to fulfill the
burdensome documentation and reporting processes, many working participants are in danger
of losing needed benefits and services.
• Inefficient. Work requirements are costly to administer and time-intensive for all involved.
Program administrators will spend more time implementing these requirements than focusing
on supporting the health, housing, and income support needs of participants. Furthermore, the
burden of proof for exemptions and compliance falls on already-struggling people. In particular,
people with disabilities who lack Social Security Disability Insurance (SSDI) and SSI benefits and
people with substantial economic disadvantages are likely to unfairly face work requirements
and struggle to document compliance with them. These sanctions also undermine the
effectiveness of economic security programs in countering recessions.
• Inequitable. Taking away access to foundational programs from people who do not meet work
requirements puts populations that are already facing systemic discrimination or other barriers,
including children, people with disabilities, caregivers, older workers, and workers of color,
further at risk. Work requirements will deepen existing inequities, including in negative physical
and behavioral health outcomes, poverty and deep poverty, and for community-wide outcomes.
Policy Recommendations
In addition to halting and reversing counterproductive work mandates, policymakers should advance an
agenda that actually would increase employment and incomes. We propose illustrative
recommendations in three categories:
1. Ensure a foundation for individuals and families, including by ensuring access to and
strengthening programs such as SNAP, Medicaid, housing assistance, and TANF, and raising the
minimum wage;
2. Strengthen family stability, including by modernizing UI and establishing a Jobseeker’s
Allowance (JSA), establishing fair and predictable schedules as well as paid leave, and reforming
the criminal justice system; and
xlvii
Musumeci, MaryBeth, and Julia Zur. “Medicaid Enrollees and Work Requirements: Lessons from the TANF
Experience.” Kaiser Family Foundation, 18 August 2017. Available at https://www.kff.org/report-section/medicaid-
enrollees-and-work-requirements-issue-brief.
xlviii
Sherman, Arloc. “After 1996 Welfare Law, a Weaker Safety Net and More Children in Deep Poverty.” Center on
Budget and Policy Priorities, 9 August 2016. Available at https://www.cbpp.org/family-income-support/after-1996-
welfare-law-a-weaker-safety-net-and-more-children-in-deep-poverty.
xlix
Rocha, Renato and Anna Cielinski. “Why the Current Workforce System is Not Suited to Help Medicaid
Beneficiaries Meet Work Requirements.” Center for Law and Social Policy, 31 October 2018. Available at
https://www.clasp.org/blog/why-current-workforce-system-not-suited-help-medicaid-beneficiaries-meet-work-
requirements.
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Unworkable & Unwise | 15
3. Support workers, including by investing in job preparation and creation through proven training
and education, and subsidized and public employment programs; expanding child care
assistance; and boosting the Earned Income Tax Credit (EITC).
Introduction
n recent years, the Trump Administration, members of Congress, governors, and state legislatures
have put forward, and in some cases implemented, new and harsher proposals to take away health
care, food, and housing assistance from people who do not meet a work requirement. The programs
being targeted for new work requirements—Medicaid, Supplemental Nutrition Assistance Program
(SNAP), and housing assistance—are lifelines for individuals and families during times without sufficient
work or earnings. Because these proposals reflect misunderstandings of these programs and
participants, they are or will be harmful to the well-being of people with low incomes. These policies
differ substantially from program to program and state to state, and variations are likely to continue to
appear. Regardless, the policies all suffer from the same flaws inherent in conditioning foundational
support on documenting and participating in approved activities. As a result, this report focuses on
these policies generally rather than on any particular one (though some key policies are described in the
Appendix). In addition, alongside proposed restrictions for immigrants’ access to,
1
budget cuts for,
2
and
the ending of other participant protections in economic security programs,
3
these new work rules are
part of a broader strategy of gatekeeping, shrinking, and undermining the system of supports for
struggling individuals and families.
4
The connection to other proposals, often proposed with similar
rationales and based on similar misunderstandings of programs and participants, suggests a need to
detail the sizeable body of evidence of the effectiveness of Medicaid, SNAP, and housing assistance in
supporting people with low incomes as they overcome challenges they face.
Medicaid, SNAP, & Housing Assistance Ensure a Foundation for Families
Research on the effects of economic security programs strongly suggests that every individual and every
family require a stable and strong foundation to be healthy and succeed in the labor market and
beyond.
5
,
6
,
7
,
8
That foundation, especially for people struggling in the labor market, is often ensured
through public benefits and services, including Medicaid, SNAP, and housing assistance. These programs
have demonstrated beneficial long-term, intergenerational effects on employment and earnings for the
children in families who participate.
9
,
10
,
11
,
12
By providing economic security for disadvantaged
individuals and families, Medicaid, SNAP, and housing assistance also advance economic opportunity.
Medicaid, SNAP, and housing assistance programs provide essential services and support to tens of
millions of individuals and families in the United States. In 2010, Medicaid kept at least 2.6 to 3.4 million
people out of poverty.
13
In 2017, SNAP and housing subsidies kept 3.4 million and 2.9 million people out
of poverty, respectively (all by the Supplemental Poverty Measure, or SPM).
14
Medicaid is a federal-state
partnership that provides health coverage for more than 1 in 5 people in the United States, including
millions of low-wage workers and their families
15
and people in need of long-term support and
services.
16
Medicaid provides vital health care coverage to many who would otherwise lack it. SNAP is
state-administered and largely federally-funded, helping approximately 1 in 8 people in the U.S.
17
purchase food—including many who are at greatest risk of experiencing hunger or poor nutrition.
18
Federally-funded housing assistance provides rental aid for some households with the lowest incomes
and is generally administered through local housing authorities, who in turn provide vouchers, directly
subsidize units in private housing developments, or build and maintain public housing
19
for fewer than 1
in 30 people in the U.S.
20
Particularly in light of the decline of Temporary Assistance for Needy Families
(TANF)
21
and General Assistance (GA),
22
which provide cash assistance to families and individuals
I
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Unworkable & Unwise | 17
respectively, and the challenges of today’s low-wage labor market, these programs are essential for
ensuring that people do not fall below a floor for material deprivation or economic resources.
23
Removing Access to Health Care, Food, & Housing Assistance Is
Counterproductive
Work requirements in programs ensuring a basic foundation for people have a long history of poor
outcomes, though recent proposals are unprecedented. New work requirements are inspired in part by
similar policies imposed on TANF recipients since 1996 that likely have contributed to increases in deep
poverty, as detailed later in this report.
SNAP and housing assistance programs have had some requirements related to work activities for some
participants in the past, but the proposals discussed in this paper would make them harsher and include
a far larger share of participants. At the federal level, longstanding SNAP time limits have substantially
limited access for many unemployed and underemployed adults, though states have routinely applied
for and received waivers from these draconian provisions.
24
In 2016, about half a million participants
lost food assistance because they failed to meet a SNAP work time limit.
25
Recent proposals would make
these SNAP rules harsher still.
26
Federally-funded housing assistance programs have experimented with
requirements related to work activities through demonstrations, but never as a part of widely-applicable
policy.
27
(For the purposes of this paper, “housing assistance programs” refer to Section 8 Housing
Choice Vouchers, Public Housing, and Project-Based Rental Assistance programs.) Until now, Medicaid
had never been tied to formal employment; its central purpose is to provide health coverage to people
with very low incomes. Removing participants and leaving them uninsured due to not meeting or
documenting work or community engagement activities is thus new to Medicaid. As of January 2019, 16
states have applied for, and one has implemented, work requirements in Medicaid; this number is
expected to grow.
28
(The legal question of whether applying such requirements through Medicaid state
waivers is consistent with the program’s purpose of providing medical care and treatment is the subject
of ongoing litigation, as discussed in the Appendix.)
29
Efforts to take benefits away from many more participants in Medicaid, SNAP, or housing assistance
programs misunderstand the populations such programs aim to serve and grossly underestimate the
harm to families and individuals as a result of these policies. The new policies also ignore the structural
barriers people with very low incomes face, including the unavailability of full-time work and the
instability of low-wage jobs today.
30
Alongside a 3.9 percent December 2018 unemployment rate, 7.6
percent
31
(12.8 million people)
32
of the civilian labor force plus marginally-attached
33
workers was
unemployed or underemployed.
34
At the same time, many communities of color continue to face
recession-like circumstances despite a lengthy period of economic growth for the U.S. For example, the
December 2018 unemployment rate for African Americans was 6.6 percent
35
—a figure that, as a
statewide unemployment rate, could be high enough to trigger permanent law Extended Benefits under
the Unemployment Insurance (UI) program.
36
This high African American unemployment rate comes
more than 114 months into an economic expansion, the second longest in U.S. recorded economic
history.
37
These indicators reveal a strong desire for greater employment than offered or available in
what otherwise may seem to some to be a full-employment labor market.
As a result, low-paid workers, people of color,
38
people with disabilities or chronic health conditions
(including mental health conditions and substance use disorders),
39
people with criminal records,
40
and
children
41
will be harmed, rather than helped, by proposals that take food, health care, and housing
assistance away if recipients do not satisfy work requirements. These programs support and promote
work, not just for adult participants but for their children when they become adults.
42
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Unworkable & Unwise | 19
Taking Assistance Away From Participants
Who Do Not Meet Work Requirements is
Ill-Informed
his section considers the appropriateness of taking away healthcare, food assistance, or housing
assistance if people fail to meet and document work and community engagement requirements—
typically a set number of hours in an approved activity each month—as an anti-poverty policy approach
within the context of broader social, economic, and other relevant factors. It outlines the ways in
which rationales for work requirements for some Medicaid, SNAP, and housing assistance
participants fall short of appreciating the roles, purposes, and impacts of these vital supports for
low-income people and their families. Lastly, the section examines often-mistaken or misleading
assumptions about who participates in affected programs and why, and what keeps participants from
working or earning more. These and other ill-informed assumptions about program participants are
apparent in what proponents have stated publicly as well as in the details of actual work requirements.
Our Economic Security System is Already Heavily Tied to Formal Employment
Newly proposed work-related rules in Medicaid, SNAP, and housing assistance warrant particular
attention because these programs serve as a lifeline to many left out of the rest of our economic
security system. Much of our economic security system, including health coverage and income supports,
conditions access on some demonstration of formal employment,
43
rather than primarily on need (see
Figure 1).
44
Contributory social insurance programs like Medicare,
45
Social Security (including disability
insurance, or SSDI),
46
and Unemployment Insurance
47
require individual or household earnings histories.
Medicaid, Supplemental Security Income (SSI), and GA taken together with Aid to Families with
Dependent Children (AFDC)—before being replaced by TANF—acted as the fallback economic security
programs for people who would not otherwise qualify for Medicare (or have access to employer-
sponsored health insurance), Social Security, and UI, primarily due to the latter programs’ requirements
of formal labor market earnings.
Even supports and services intended for those who are least able to work in formal employment, like
AFDC’s replacement, TANF, require labor-market-focused engagement for many participants.
48
As TANF
and GA have shrunk dramatically, the relatively newer Earned Income Tax Credit (EITC) and even more
recent Child Tax Credit (CTC), which both require formal earnings, have grown substantially. Child care
assistance has expanded and contracted over the past few decades,
49
but often targets those with
formal employment; for unemployed jobseekers, it is unavailable in several states and significantly
restricted in most of the remaining states.
50
Overall, our economic security system strongly and
increasingly requires formal work and offers less and less to those struggling to find and maintain
employment.
51
Figure 1. Major economic security programs require earnings & meeting labor-market-oriented tests
Role of labor market earnings & activities in accessing key economic support programs
T
PROGRAM
DESCRIPTION
LABOR-MARKET-RELATED ELIGIBILITY
REQUIREMENTS
Social Security (SS) &
Disability Insurance
(SSDI)
SS: Provides retirement & survivors’ benefits
for workers;
52
SSDI: Provides benefits for
individuals with a work-limiting disability
53
SS: Prior household earnings to claim; SSDI: Prior
individual earnings to claim
Medicare
Provides health insurance for individuals aged
65+, or after 2 years of SSDI receipt
54
Prior household earnings to enroll, or current
income to buy-in for citizens or permanent
residents 65 & over
UI
Provides unemployment benefits to eligible
workers
55
Prior individual earnings as employee &, generally,
documentation of current job search to claim
Working Family Tax
Credits
EITC: Credit for workers with a low to
moderate income;
56
CTC: Credit for qualifying
dependents claimed by taxpayer;
57
CDCTC:
Credit to offset child care costs
58
Current household earnings to claim EITC, CTC, &
CDCTC
CCDBG/CCDF
Provides child care assistance for low-income
families so they can work or attend a job
training or educational program
59
Typically targets people with formal employment;
unavailable for unemployed jobseekers in several
states & significantly restricted in most remaining
states
60
TANF
Provides temporary cash assistance for low-
income families with children
Participation in labor-market-oriented activities
(exemptions: single parents with children under 12
months old & parents caring for family member
with a disability
61
others differ by state)
Medicaid
Provides health insurance for qualifying low-
income individuals
Historically, no minimum earnings to claim;
recently work and community engagement
requirements proposed, approved, or
implemented in 16 states
62
SNAP
Provides nutrition assistance for eligible low-
income individuals & families
Time limits for some people without jobs of
working age if area lacks waiver;
63
USDA proposal
would limit waivers to areas where unemployment
rate is over 7%
64
Housing Assistance
Provides rental assistance for some low-
income households, through vouchers, directly
subsidized units in private housing
developments, or public housing units
No minimum earnings to claim; work
requirements in: MTW demonstration (9 PHAs),
65
president’s FY19 budget (for project-based
assistance),
66
Proposed Fostering Stable Housing
Opportunities Act of 2018 (for youth aging out of
foster care)
67
Source: Georgetown Center on Poverty and Inequality, 2019
In this context, proposals to establish or expand requirements denying Medicaid, SNAP, and housing
assistance—programs that prevent destitution
68
, disease,
69
and even death
70
for the most vulnerable in
our society—because participants fail to meet and document approved work and community
engagement requirements make little sense. Determining eligibility or benefits for these programs by
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Unworkable & Unwise | 21
requiring ongoing demonstration of formal work or work-related activities will tend to compound
disadvantage,
71
trapping rather than empowering people when they are struggling the most.
72
Nearly All Program Participants Have Worked, Still Work, & Will Work in the
Future—or Face Major Barriers to Work, Due to Factors Such as Age or Disability
The push for these new requirements reflects an incomplete understanding of the low-wage labor
market and the lived experiences of people who are attempting to navigate it to find, secure, and
maintain employment compatible with their own health and family responsibilities. A primary
assumption
73
of policies to take away benefits from participants in Medicaid, SNAP, and housing
assistance who do not meet a work requirement is that adults who should be able to work formally can
and will do so, if properly incentivized.
74
However, for all three programs, a multitude of evidence
demonstrates that most participants who can work already do. Most adults of working age who do not
have a work-limiting disability and participate in Medicaid,
75
SNAP,
76
and housing assistance
77
work or
have recently worked. For the majority (over 80 percent) of SNAP participants, who have worked before
SNAP participation and will work again (within a year of SNAP participation), SNAP provides temporary
support to help weather spells of un- or under-employment, or to help supplement low and inconsistent
pay.
78
Among SNAP recipients of working age who do not have a work-limiting disability, over 50 percent
work while receiving SNAP.
79
Among those not working, two-thirds of recipients are children, elderly
people, and people with disabilities (see Figure 2).
80
This is similar for SNAP households, among whom
about 60 percent of households with children and an adult of working age who did not have a work-
limiting disability had work earnings in 2015.
81
In fact, the proportion of SNAP participants in households
with a worker has increased sharply over the last two decades, suggesting SNAP plays a strong role in
supporting people and families during periods of underemployment.
82
Medicaid and housing assistance participants who do not qualify for disability insurance typically also
live in working households. Of the nearly 25 million working-age Medicaid recipients who do not qualify
for SSI, 8 in 10 live in working families or work themselves.
83
In 2017, 61 percent of participating non-
elderly families had at least one member employed full-time, and an additional 14 percent had someone
working at least part-time.
84
This population is likely to account for a significant share of Medicaid
recipients who would lose coverage due to the burdens of satisfying reporting requirements, as
discussed in further detail later in the paper.
85
Similarly, an analysis of federal housing assistance data
found that 88 percent of households that received rental assistance in 2010 were elderly or had
someone with a disability (55 percent), were working or had recently worked (28 percent), or were likely
to face work requirements through TANF (5 percent) as it is.
86
Figure 2. Vast majority of Medicaid, SNAP, & housing assistance participants not engaged in formal
employment due to caregiving, school, retirement, or sickness or disability
Main reported reason for not working among Medicaid, SNAP, & HUD-assisted housing participants,
2017
Participants Face Barriers to Employment That Work Requirements Ignore
Many program participants face barriers to employment that can make it challenging or impossible to
maintain steady employment that keeps them and their families out of poverty.
87
Some face obstacles
to work, such as significant health problems or caregiving responsibilities, not addressed adequately in
work requirement proposals.
88
Others need more advanced skills but cannot participate in education or
training without income supports,
which are in short supply for
people pursuing such
development. The remaining
individuals who are not working
face other sizeable individual
and/or structural barriers to
employment which, regardless of
economic conditions, work
requirements will not help
address.
89
,
90
Box 1.
While this paper focuses on recent iterations of work requirements
in foundational social assistance programs, the historical context is
illuminating. Modern work requirements follow a long history of
racially-motivated critiques of programs supporting living
standards; some proposals have relied on racial bias—fueled, in
part, by false narratives about African American women in
particular—to garner support.
(continued on the next page)
Box 1 cont.
THE RACIAL HISTORY OF WORK REQUIREMENTS
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These barriers can be categorized roughly into six basic groups: limited education or mismatched skills,
health and disability, criminal justice system involvement, caregiving and family responsibilities, limited
economic and social resources, and demographic and other individual characteristics (including
immigration status), especially as they interact with systemic racial discrimination.
107
These
characteristics and how they may manifest as barriers to employment
108
are briefly outlined in Figure 3.
Although many think of the Social Security Act of 1935 as the dawn of “welfare” in the United States,
federal social assistance began with the mother’s pension (the predecessor to Aid to Dependent
Children, or ADC, later renamed Aid to Families with Dependent Children, or AFDC).
91,92
At first,
primarily white women primarily accessed mother’s pensions. During this time, policymakers
designed the programs to allow mothers to meet their basic needs without working outside of the
home. Only once more African American women began to participate, were work requirements
implemented.
93, 94
The programs also attempted to restrict women of color’s access to basic needs
assistance. In the 1930s, when there was unmet demand for domestic work and for labor during the
harvesting seasons, local administrators of the Federal Emergency Relief program often seized the
opportunity to deem Latina and black mothers “employable” under the “employable mother” rule—
forcing them to work outside of the home to receive benefits.
95
Relief programs thus “had the dual
function of keeping white mothers at home and forcing Latinas and blacks into the low-wage labor
market.”
96
States also enforced “employable mother” rules in ADC.
97
Place has also played a role in the history of racial discrimination and work requirements. In 1910,
most African American people lived in the South.
98
Between 1915 and 1970, over 6 million African
American people fled the south to escape economic exploitation, extremely limited economic
opportunities, and pervasive racial terrorism (such as public lynching and mob violence) in the hope
of a better life—a period now known as the “Great Migration.”
99, 100
As more African Americans
flowed north, northern states began to adopt some of the work requirements already prevalent in
relief programs in the South.
101
Equally salient have been the harmful race-based narratives generally surrounding people
experiencing poverty, particularly harming people of color. In many cases, these narratives were
employed to appeal to working-class whites and garner support for policies to reduce human
services spending.
102, 103
These false narratives ignore the realities of the labor market discrimination
and exclusion people of color face, in particular—and the fact that most people who receive public
benefits who can work, do so.
Policy that is not conscious of racial inequities can exacerbate racial injustice. Recently, a 2018
Michigan bill proposed requiring proof of working 30 hours per week in order to access Medicaid—
unless the individual lived in a county with an unemployment rate over 8.5 percent.
104
At face value,
exempting people in high-unemployment areas from work requirements seems practical and fair. In
reality, however, the areas that would have qualified were largely populated by rural whites.
105
In
contrast, residents of majority-black Detroit and Flint would not have been exempt because,
although both cities had qualifying unemployment rates, the larger counties did not. As a result, the
exemption would have largely excluded African Americans in cities.
106
Figure 3. Selection of barriers to employment unaddressed by work rules
Source: Georgetown Center on Poverty and Inequality, 2019
Limited Education, Experience, & Skills
Limited educational attainment (having less than a high school degree or equivalent) may be one of the
most prevalent barriers to employment among low-paid workers.
109
People without a high school
degree or equivalent often cannot access programs developing the training necessary to attain technical
skills, credentials, and normative professional skills.
110
Not having enough formal, recent, or relevant
work experience may also make it difficult for workers to re-connect or stay connected to the labor
force. Workers may also experience significant barriers to getting new skills. For example, access to
school and training may be limited because of barriers such as a lack of available and affordable
transportation,
111
child care,
112
and other prohibitive costs.
113
Older workers may lack access to training
for new technology used in their industries, as well.
114
Limited Economic & Social Resources, Including Place-Based Barriers
Material hardship and economic insecurity makes obtaining or maintaining employment more
challenging. Other factors, such as geography and social network limitations, can also make it more
BARRIER TYPE
POPULATION WITH BARRIER
Limitations in Workers’ Overall
Productivity
Human
Capital
Limited Skills & Education
Immigration Status: Recent Immigrant, Especially
Refugee/Asylum Seeker
Personal
&
Logistical
Limited Economic & Social Resources: Transportation,
Housing, Stability, etc.
Caregiving & Other Family Responsibilities
Health & Disability: Work-limiting Physical, Mental, or
Sensory Health Condition or Disability
Systemic Discrimination by
Employers
Legal
Immigration Status: Undocumented Status
Criminal Justice System Involvement
Demographic
Apparent Health Condition or Disability
Age
Race, Ethnicity, & Origin
Sexual Orientation & Gender Identity (SOGI)
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Unworkable & Unwise | 25
difficult for people to work. For example, housing-related instability due to limited economic
resources—such as the loss or threat of losing housing assistance, frequent moves, and experiencing
homelessness—can have extraordinarily negative impacts on one’s ability to remain attached to the
labor force,
115
particularly for people with disabilities.
116
Moving also can exacerbate transportation
issues for lower-income workers, compounding barriers to job searching
117
and work.
118
,
119
Groups likely
to face transportation barriers include individuals living in rural areas,
120
individuals with disabilities,
121
and low-income individuals. At-home internet access is also increasingly important for workers and
jobseekers to be successful in the labor market (and for complying with work reporting
requirements),
122
and yet, among current Medicaid enrollees in the U.S., more than a quarter “do not
use the internet.”
123
Even if one’s housing situation is stable, place-based factors (such as geography and
social network limitations), can create obstacles to employment for many. For example, jobseekers
living in areas where there are limited job opportunities, including rural areas
124
and on American
Indians and Alaska Natives (AIAN) tribal lands,
125
may find it difficult to obtain employment.
Caregiving & Other Family Responsibilities
Caregiving and family responsibilities, in the absence of adequate work-family supports and policies, can
also impact one’s ability to participate in the formal labor force.
126
,
127
In Georgia, one of the states
contemplating Medicaid work requirements,
128
over one-quarter of Georgia parents with children under
age 5 “reported that, in the past year, they or someone in their family experienced a significant
disruption to employment—quitting, not taking, or greatly changing a job—due to challenges with child
care.”
129
The same study estimates that annually, child care-related challenges for parents cost the state
at least $1.75 billion “in lost economic activity” (such as through adverse employment-related
outcomes).
130
Additionally, among all working-age Medicaid participants in the U.S. who are not
working,
131
nearly one-third (28 percent) cited caregiving or other home responsibilities as preventing
them from working.
132
Health & Disability
Work-limiting physical, mental, or sensory health conditions and disabilities present barriers to
employment for many.
133
This may be due to limits to capacity for work, both real and those perceived
by others.
134
About 1 in 5 childless adults enrolled in SNAP in 2014 who did not have income from a
disability program reported either a disability that prevents or limits the type of work they can do such
as hearing, walking or climbing stairs, or concentrating and making decisions due to a physical, mental,
or emotional condition.
135
Additionally, a study found that over one-third of jobseekers with disabilities
(36 percent) experienced discrimination from prospective employers, such as pre-emptive employer
judgment of their ability to do the job.
136
,
137
From FY1997-FY2016, one-third of employment
discrimination charges filed with the U.S. Equal Employment Opportunity Commission were for
discrimination on the basis of disability.
138
People of color with disabilities have higher rates of
unemployment on average than their white counterparts.
139
Older workers of color are also more likely
to be in poverty
140
and more likely to have disabilities,
141
which can increase their obstacles to gaining
and maintaining employment and increase their need for health coverage.
Criminal Justice System Involvement
The labor market is replete with barriers that undermine the ability of formerly incarcerated people to
attain stable and quality employment, including employer discrimination, low educational and skills
attainment, and even occupational licensing restrictions.
142
In fact, data shows that up to half of
returning citizens remain unemployed for up to one year post-release.
143
Discrimination in the labor
market due to past criminal justice system involvement presents significant challenges to obtaining
employment. Individuals with criminal records face systematic employer discrimination,
144
and race can
further compound disadvantages in the labor market for people reentering the workforce after
incarceration. The barriers to employment are particularly severe for African-Americans and Hispanics,
who are incarcerated at five times and three times the rate of whites, respectively.
145
Furthermore,
black men with a criminal record are three times less likely to get a callback during the hiring process,
while white men with a criminal record are half as likely to get called back than their same-race
counterparts who do not have a record.
146
Systemic Discrimination
Employer discrimination based on race/ethnicity, immigration status, and sexual orientation and gender
identity (SOGI) present significant barriers for individuals in the labor market.
148
A 2017 study found that
white applicants were more likely to receive callbacks than their Latino and African American
counterparts, and that discrimination against black job applicants has not meaningfully declined in the
last three decades.
149
Recent immigrants may face employer discrimination—in addition to difficulty
acquiring the skills necessary to easily succeed in the U.S. labor market, such as English proficiency.
150
Additionally, SOGI-related characteristics are associated with a greater risk of low pay and financial
insecurity, which can compound the need for services and supports.
151
Forty-two percent of women say
they have faced gender discrimination in the workplace, including differential pay based on gender.
152
There are no federal laws prohibiting Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) workers from
being fired on the basis of their sexual orientation or gender identity.
153
LGBTQ individuals also are not a
protected class under the Fair Housing Act, which augments their risk of facing housing
discrimination.
154
As previously discussed, housing instability and homelessness can increase the
difficulty of finding and keeping work.
155
Age-based discrimination in the job market can create barriers for workers in their 40s,
156
50s, and 60s.
About 3 in 5 older workers say they have experienced or seen age-based discrimination in the
workplace.
157
One study examining the submission of fictitious resumes with differing ages and genders
found employer callback rates were lower for older workers, particularly older women.
158
Older women
near the perceived retirement age face not only age-based discrimination, but also gender-based
discrimination (which may manifest through prejudiced ideas about women’s physical appearances).
159
Older workers who are women of color face often increased barriers, as they contend with
discrimination on the basis of their age, gender, and race.
Box 2.
In response to the evidence suggesting these new work requirements are not appropriate nor workable for
Medicaid, SNAP, and housing assistance, proponents may point to exemptions as a defense.
147
While exemptions
may protect certain individuals, they invariably fall short of taking into account the challenges many low-income
people and their families face. More importantly, the new requirements and exemptions to them operate under a
de facto 100 percent participation requirement, giving caseworkers little discretion and placing the burden of proof
on program participants (see section “Revoking Access to Work-Supporting Programs Due to Rigid & Impractical
Work Requirements is Inefficient” for more information). As a result, the designation of exemptions itself is likely
to reflect this lack of understanding.
EXEMPTIONS CAN BE ILL-INFORMED
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Box 2 Cont.
Generally, new work requirements in SNAP, Medicaid, and housing assistance exempt older participants
(depending on the state, beginning at 50 – 65 years of age), and people under age 18 – 19 (depending on the
program).
160
In SNAP, working-age participants are exempt if they have a disability; are providing caregiving for a
family member with a disability or a child under the age of six; are enrolled in training or school (including higher
education); or are receiving treatment or rehabilitation services.
161
In Medicaid, people are generally exempt if
they are elderly, pregnant, or under age 19.
162
For public housing authorities (PHAs) that impose work
requirements in housing assistance programs as a part of a Moving to Work (MTW) demonstration (see Appendix
C. for more information), while additional exemptions depend on the individual, these PHAs already exempt
participants who are older, have a disability, or are “physically or mentally unable to engage in work activities.”
163
To be sure, exemptions may appear to protect those who are unable to comply with new requirements. In reality,
exemptions are themselves challenging to receive, and may have contribute to the harmful short- and long-term
outcomes of work requirements for individuals, their families, and their communities.
Exemptions may employ an unrealistic view of caregiving and other family obligations. For example, exemptions
may not account for persisting child care needs once children enter primary school. The proposed 2018 House
Farm Bill included increased work requirements and would have exempted parents with children under age 6 from
its expansion of the work rules for SNAP, but not parents with children in elementary school.
164
Similarly, while
some Medicaid waivers have exempted parents from work requirements, two of those approved so far—Indiana
and New Hampshire—do not exempt parents with children over the age of six.
165
Yet, no state requires that public
schools ensure that school times and dates align with full-day or full-year work.
166
For many work-eligible parents
unable to afford or secure child care, the imposition of work requirements forces impossible choices, between
either leaving their elementary school-aged children unattended or at risk of neglect to maintain Medicaid
coverage, or staying with their children but losing coverage because they cannot meet the required hours-worked
threshold.
Even when exemptions allow for broader consideration of barriers related to disability and health, they can be
difficult to access and can result in people being inappropriately subject to work requirements. For
administrative ease, states have a tendency to use participation in disability assistance programs, such as SSDI/SSI,
private disability insurance (PDI), temporary disability insurance (TDI), and Interim Assistance, as proxies when
making eligibility determinations. However, in many programs little if any support is available to help people
navigate the exemption process,
167
there is no requirement for state administrators to do so, or the incentives for
the worker or administrative agency do not support offering this assistance.
168
As it is, the federal programs that
provide disability benefits, such as SSDI and SSI, have strict qualification tests,
169
leaving many people with a work-
limiting disability likely ineligible. As a result, many people with work-limiting disabilities or chronic conditions likely
would face work requirements and thus lose their benefits.
170
Exemptions do not always support work preparation activities, such as education and training. Although some
states are exempting students or allowing class hours to count towards the requirement, many states are not.
171
Even within states where students are technically exempt or can count their coursework as work, the rigidity of the
exemptions may not make sense within the context of education and training programs. For example, the ability to
count an educational program towards one’s participation requirement often falls short of the time it takes to
complete the degree or program. In addition, for states that choose not to count class hours as work, students will
be forced to work more.
172
Low-income students who work over 15 hours per week are more likely to have lower
grades and lower program completion rates.
173
Medicaid, SNAP, & Housing Assistance Support Work
SNAP, Medicaid, and housing assistance are essential programs that help keep millions of people and
their families out of poverty in the U.S.
174
By providing food assistance, health care, and housing
support, these programs help people experiencing economic insecurity make ends meet and help those
who are able to work, work. They also enable unemployed individuals to look for employment. The
benefit structures of SNAP and housing assistance are designed to both support work and minimize any
potential work disincentives, while Medicaid provides work-supporting health care for millions of low-
paid workers.
175
In other words, all three programs support working adults and their families rather than
significantly substituting or dis-incentivizing employment. They also help fill in gaps left by the low-wage
labor market.
176
MEDICAID SUPPORTS WORK
Due to the U.S.’ employer-based health insurance system, which falls particularly short for workers in
low-wage industries, Medicaid acts as the backstop for many (see Figure 4).
177
It provides essential
health care to over 76 million low-income Americans who would otherwise not have coverage.
178
Having
access to health care, like Medicaid provides, can ensure that someone living with a chronic health
condition or disability—or providing caregiving for a family member with one—can best manage their
condition and maintain attachment to the labor market.
179
Research also suggests that increased
Medicaid health coverage under the Affordable Care Act (ACA) makes it easier for people to find and
maintain work. For example, a study of expansion enrollees in Ohio found that among unemployed
jobseekers, 74.8 percent said Medicaid made it easier to seek employment.
180
The study also found that
for a majority of enrollees, Medicaid made it easier to maintain employment.
181
A separate study of
enrollees in Michigan found similar results.
182
Conversely, unmet behavioral health (mental health and
substance use disorder) needs can make it more difficult to gain and maintain employment.
183
A
substantial and growing body of evidence also links the Medicaid expansion to positive effects for
participants’ (and their children’s) health, as well as for their access to services,
184
financial security, and
general well-being.
185
,
186
As many full- and part-time low-wage workers do not have access to employer-
provided health insurance, Medicaid ensures that workers have the tools to stay healthy and succeed at
work.
187
Taking Medicaid coverage away from people who do not meet an employment, training, or
community engagement requirement could place needed health care out of reach for the very
populations whose future employment and earnings most depends on accessing health care.
Medicaid also acts as a connector to other work-supporting programs and assistance. Recognizing the
impact of social determinants—such as housing
188
—on health, the ACA and other policies provide
opportunities
189
for states to support housing-related and home- and community-based services
through Medicaid.
190
For example, under certain waivers, state Medicaid programs can provide
supportive services for securing and retaining housing or living in non-institutional settings for people
experiencing homelessness and people with disabilities.
191
,
192
Similarly, state Medicaid programs can
also support work by referring enrollees to (voluntary) job training and search programs and “cover[ing]
the services needed to keep people healthy and enable them to work.”
193
For these reasons, many
leading organizations of medical professionals in the U.S. have voiced their opposition to recent CMS
approvals of state waiver applications for Medicaid work requirements, arguing that the new policies
would roll back progress under the ACA and result in a loss of coverage and care for low-income
families
194
and people with disabilities,
195
chronic illness,
196
and behavioral health conditions
197
—all of
which would lead to increased system-wide costs and poor health outcomes.
198
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Unworkable & Unwise | 29
Figure 4. 1 in 5 people in U.S. are insured through Medicaid
Breakdown of U.S. Population by insurance coverage, 2017
SNAP SUPPORTS WORK
As with Medicaid, many SNAP recipients likely to be subject to this new brand of SNAP work
requirements (as has been seen in efforts such as the proposed 2018 House Farm Bill) are already
employed.
199
In their case, SNAP is supplementing low wages, not substituting for work. SNAP provides
temporary nutrition support to workers to help smooth income and employment volatility characteristic
of low-wage jobs.
200
Low-wage jobs are precarious for workers trying to maintain stable and consistent
employment, as they have to contend with challenges related to low pay, such as unpredictable
schedules, a lack of worker protections, and benefits such as paid sick leave. As a result, workers in low-
wage positions are particularly vulnerable to periods of economic insecurity and instability.
201
SNAP’s
monthly benefits help individuals manage temporary under- and un-employment that can arise from
these factors, and help supplement inconsistent and inadequate earnings.
202
HOUSING ASSISTANCE SUPPORTS WORK
As for housing assistance, research indicates that when people have affordable, accessible, secure, and
adequate housing, they are better situated to get and retain employment and sustain improved health
(see Figure 5). For example, having a stable address can help a low-wage worker maintain regular
transportation to a job and sustain ongoing relationships with child care and/or health care providers.
203
Housing assistance also can help bridge the gap between stagnant, low wages and rising costs of living.
Figure 5. Moving to a lower-poverty neighborhood can improve physical & mental health
Prevalence of depression, diabetes, and obesity among adults participating in the HUD Moving to
Opportunity demonstration (MTO), 1994-1998
For many in the U.S., there is a fundamental mismatch between wages and the cost of housing. One in
four renter households (11.4 million households) have low incomes and cannot afford their rents.
204
,
205
Many others—over 20 million renter households—experience “housing poverty,” or the inability to
afford basic needs such as food, health care, and transportation after paying rent.
206
Thus, housing
assistance can promote employment if it prevents or mitigates these problems.
MEDICAID, SNAP, & HOUSING ASSISTANCE IMPROVE LABOR MARKET OUTCOMES FOR THE
NEXT GENERATION
In addition to supporting work and helping families in the short-term, research indicates that Medicaid,
SNAP, and housing assistance programs generate positive longer-term—and even intergenerational—
labor market, educational, and health outcomes. For example, multiple studies have found that
Medicaid expansions, which increased access to care in-utero and in childhood, resulted in higher high
school and college completion rates and lower rates of some health conditions in adulthood.
207
,
208
The
more years someone accesses Medicaid during childhood, the stronger the effects—including increased
college enrollment and reduced births to teenagers.
209
Links to positive impacts on one’s labor market
outcomes in adulthood are clear.
210
Housing assistance, to help families move to lower poverty
neighborhoods, has been shown to improve earnings and college attendance rates for children whose
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families moved before they reached 13 years old.
211
With regard to SNAP, one seminal study found that
childhood access to SNAP led to a significant reduction in adulthood of health conditions like diabetes
and obesity, as well as increased educational attainment, employment, and earnings for women (see
Figure 6).
212
,
213
When people are able to come home to secure and stable housing, put food on their
tables, and take care of their health needs, they are able to succeed in a number of ways, including at
their jobs. This research suggests that taking away vital resources undermines a worker’s ability to meet
life’s demands, let alone thrive.
Figure 6. Adults who had access to SNAP as children were more likely to complete high school & less
likely to face major health obstacles
Difference in likelihood of adult outcomes for individuals born just before & after introduction of food
stamps (now known as SNAP)
The Details of Harsh Work Requirement Proposals Make Little Sense for Low-
Paid Workers
Even when individuals work, many struggle to earn enough money to maintain basic living standards,
often due to job-based factors beyond their control. Income volatility, low pay, involuntary part-time
status,
214
and a lack of access to health insurance and other important work supports, such as paid time
off for medical and family leave, are common challenges in the low-wage labor market.
215
Despite the
involuntary and unpredictable fluctuation in hours, pay, and schedule that is common among low-paid
workers, work requirements are not structured to accommodate such realities.
216
Work requirements
also do not consider the interrelated challenges that result from not being paid a living wage or having
limited control over one’s schedule--including being unable to schedule and afford child care and
transportation, and access other work supports and opportunities.
217
The low-wage labor market
demands an inordinate amount of flexibility from workers; yet, with work requirements, government
offers the opposite: demanding, unyielding rules with harsh sanctions that fail to accommodate or
account for the conditions many low-paid workers face. In addition, the frequency and level of
documentation required can be unreasonable, particularly when considered within the context of
typical challenges for low-wage workers that many better-paid full-time and salaried workers do not
face.
218
All of this suggests that work requirement supporters either misunderstand or disregard the
nature of the modern low-wage labor market.
LOW-WAGE EMPLOYERS ROUTLINELY PROVIDE UNEVEN & INSUFFICIENT WORK HOURS
Many people in low-income families are working at least part of the time, either cycling in and out of
jobs or stuck in part-time positions.
219
Of the workers below the federal poverty line in 2016, nearly half
were usual part-time workers (defined as working fewer than 35 hours per week).
220
In 2015, nearly 1 in
5 workers were on unstable work schedules, due to working on-call or having irregular shifts.
221
This
means that people who work more annual hours than mandated by a work requirement but who have
irregular hours could fail to meet a “work requirement” of a set number of hours per week or month,
and could lose benefits.
222
,
223
The restaurant and food service industries, which provide a substantial
portion of the country’s low-wage jobs,
224
often require employees to accept unstable work schedules.
These schedules may constantly change the days and times someone works, along with how many hours
they are assigned. In 2016, about 10 percent of working Medicaid enrollees had jobs in the restaurant or
food service industry.
225
Also in industries like retail, the numbers of hours per month may fluctuate
dramatically from season-to-season, and it is not uncommon for workers to have gaps between jobs.
226
A Hamilton Project study revealed the flaw in looking at employment at a single point of time when
designing policies to encourage work, which proponents of work requirements, such as the Trump
Administration’s Council of Economic Advisers (CEA), have done.
227
According to The Hamilton Project’s
empirical analysis, work requirements penalize people for normal movement between jobs and other
behaviors symptomatic of modern labor market conditions. Looking at employment at only a single
point in time is likely to expose a greater number of people to losing assistance and will harm many
people actively participating in the labor force.
228
LOW-PAID WORKERS HAVE LIMITED CONTROL OVER THEIR WORK HOURS
Conditioning Medicaid, SNAP, and housing assistance on meeting rigid mandates for ongoing
documentation of monthly minimum work hours would punish working people for factors out of their
control. For example, the employer of a person participating in SNAP working a 15-hour-per-week job
may not offer an extra shift to meet a work mandate, costing their family their nutrition assistance.
229
Or, as would be the case under the Kentucky Medicaid waiver, a restaurant worker could lose their
Medicaid for six months if their employer cuts their shifts for a week or two because business is slow.
For a working parent, the variability of their hours could mean having to quit their job because their
assigned work schedule does not fit with the child care they can arrange—and then, on top of being
unemployed for a month or two until they are able to find another job, losing SNAP or Medicaid as well.
Unstable work arrangements can be especially difficult for those with caregiving responsibilities, given
the challenges in aligning child or elder care schedules with changing work hours or affording care on a
strained budget with unpredictable income.
230
,
231
Further, even jobs that are billed as “full-time” may not always be so. A study of work sites in four
industries (hospitality, retail, transportation, and financial services) found that none of the employers
included “guaranteed a minimum number of hours for employees in hourly jobs – full-time or part-
time.”
232
In the study, “workers in full-time positions in airline catering companies were regularly sent
home when flights were cancelled or delayed, and at least some housekeepers, food service workers,
and sales associates in full-time jobs were not scheduled for full-time hours some weeks.”
233
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PUNITIVE, INFLEXIBLE RULES ARE POORLY ALIGNED WITH THE LOW-WAGE LABOR MARKET
Work requirement proposals can have rigid, punitive elements that are incompatible with the
movement in and out of jobs in the low-wage labor market that is commonplace. For example, lockout
periods in many new work requirements proposals prevent sanctioned recipients from re-applying for
benefits until a certain amount of time has passed. Even if participants become compliant again, they
cannot get the work supports they may need to keep their job until after the lockout period has ended.
In Arkansas, the first state in which new Medicaid work rules took effect, low-income adults who lose
their benefits for not documenting enough work hours must wait until the start of the new calendar
year to reapply.
234
Evidence from TANF also illustrates the incompatibility of this punitive approach: in
2011, Kansas imposed a three-month lockout period for families after the first instance of
noncompliance, with harsher penalties for each following instance.
235
Four years after exiting the
program, parents affected by the sanctions had median earnings that were only 11 percent of the
federal poverty line.
236
While their employment rates for one year immediately before and after exiting
TANF were virtually the same, participants’ employment was markedly lower in the quarter right after
their exit. This indicates that they likely still faced the same unsteadiness in their job prospects, and
because of sanctions and the lockout, they also had no fallback assistance.
237
NEW RULES CAN MAKE MEDICAID ACCESS IMPOSSIBLE FOR SOME
In non-Medicaid expansion states, the new work tests are presenting a Catch-22 for some workers. If
one works enough to meet the designated hour amount, their income becomes too high to qualify for
the program. Unfortunately, as many low-wage jobs do not provide employer-sponsored health
insurance, this is likely to leave many workers without any sort of health insurance.
238
This trend is
especially prevalent in rural areas.
239
States that did not expand Medicaid under the ACA but have
proposed work requirements (such as Mississippi, Oklahoma, and Kansas) have some of the strictest
eligibility rules in the country.
240
For example, in Mississippi (a state that has proposed a 20 hours/week
requirement), to be eligible for Medicaid, family income has to be lower than 27 percent of the poverty
line, or $370 a month for a single parent with one child.
241
However, if the parent worked 20 hours a
week at minimum wage in order to fulfill the work requirement, they would earn $580 and become
ineligible for Medicaid.
242
This suggests the purpose of such a requirement is not to encourage work, but
to reduce the number of people participating in Medicaid.
Taking Benefits Away from People Who Do
Not Meet a Work Requirement is
Ineffective
aking food, housing, and health care assistance and coverage away from people who are unable
to successfully secure and document work or community engagement is more likely to increase
poverty than decrease it. Such efforts will also do little to increase work and earnings among
program participants. This result is consistent with the failure of these new, formal employment-
based policies to address the underlying reasons people must rely on such programs in the first place—
such as the nature of the low-wage labor market and the significant un- and under-addressed barriers to
work many face. This section discusses such findings and outlines current and previous attempts to take
away supports based on work tests. It then discusses why taking Medicaid, SNAP, and housing
assistance benefits away in this way is ineffective at achieving the stated goals of increasing
employment and decreasing poverty. The section closes by discussing several serious accountability
issues for states pursuing or implementing these policies.
243
Removing People Unable to Meet a Work Requirement from Vital, Work-
Supporting Programs Has Limited Effects on Employment
Research indicates that mandatory work programs have very limited efficacy as a strategy for promoting
stable employment. First, as noted earlier, the vast majority of work-capable adult participants in
SNAP,
244
Medicaid,
245
and housing assistance
246
already work. For the minority who are of working age,
do not have a work-limiting disability, and are jobless, work requirements do little to promote work or
address barriers to work. They have modest effects on participant behavior in the short-term, do not
foster labor market success in the long run, and lead to increased hardship for many families.
247
AVAILABLE EVIDENCE SUGGESTS THAT FEW WILL BENEFIT, BUT MANY WILL LOSE NEEDED
SUPPORTS
Contrary to some supporters’ claims,
248
a body of evidence from random assignment experiments
testing the impact of mandatory work programs that operated more than 20 years ago under the AFDC
program suggests that they consistently have underwhelming effects on employment. (Notably there
have not been many rigorous evaluations of TANF work rules.)
249
An evaluation of 11 “welfare-to-work”
programs in the AFDC era found that many participants were likely to work irrespective of whether they
faced work rules, though the work requirement may have hastened their entry into the labor force.
250
When welfare-to-work participants did see increased employment rates and earnings, the increases
were small and often did not last over time (see Figure 7).
251
Programs generally also failed to produce
stable employment.
252
Instead, work rules led to participants losing assistance, which impacted
participants for much longer than any increased employment or earnings.
253
Lower rates of assistance
were due to participants being sanctioned, lower take-up rates, and reduced benefit amounts as
participants had higher incomes.
254
There is no doubt that imposing work requirements on foundational
programs means that many participants will lose needed support.
255
T
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SNAP work-related time limits have had similar results. The available evidence suggests that at best
these harsh policies did not help participants exit poverty or even deep poverty, if they had any
measureable effect on employment at all.
256
What is clear is that SNAP time limits, like other forms of
work requirements, are most likely to affect participants who are already living in deep poverty, making
it even harder for them to become meet their basic needs, let alone find work.
257
As for Medicaid,
studies on the link between work and health show that access to health insurance has a positive effect
on a person’s ability to find and keep work.
258
A study on the potential impact of taking Medicaid away
from individuals who do not meet a work requirement in Kansas suggests that we should expect similar
results in Medicaid.
259
The study found that, among unemployed enrollees likely to face work
requirements, just 11 percent said the requirements would increase their likelihood to job search.
260
Figure 7. In experimental evaluations, work requirements had limited impacts on employment, which
shrank or even reversed within 5 years
Difference in employment rates between disadvantaged participants subject to work requirements &
those who were not after introduction of work requirements in 1990s
INCREASING EMPLOYMENT & INCOMES REQUIRES RESOURCES & STRATEGIES NOT PROVIDED
BY WORK REQUIREMENTS
For the minority of program participants who are unattached to the labor market, policies to take away
benefits from people who do not meet a mandatory work requirement are likely to be ineffective. Most
programs devote few if any resources to addressing participants’ often-significant barriers to
employment.
261
,
262
,
263
Evaluations of the AFDC-era programs that levied work requirements on
participants (all precursors to the work requirement added into the 1996 law that created TANF) found
that the few programs that did have lasting effects on increased employment were those that combined
the mandate with training, subsidized employment opportunities, wraparound supports, and placement
assistance for participants with significant barriers.
264
(Voluntary subsidized employment programs that
provide essential wraparound services appear particularly promising at improving employment and
earnings—such as the New Hope for Families and Children-Milwaukee, which provided subsidized child
care, among other supports.)
265
Overall, however, even in the programs considered most effective, most
of the participants with major obstacles to employment did not successfully enter the labor force.
266
Evidence from SNAP Employment and Training programs (E&T) also show that helpful strategies for
participants included “individualized assessments, addressing barriers to employment, and helping
participants gain skills and experience[;]”
267
the most successful E&T programs providing these services
were also voluntary.
268
However, these resources still did not reach many of the participants facing
significant barriers to work, and job retention resources for these populations needed to be expanded to
build on the success the program did have.
269
Under the new proposals to take benefits away from people who do not meet a work requirement,
enrollees are likely to encounter a similar or even greater dearth of work-supporting resources, due in
part to statutory and other structural restrictions. As mentioned earlier, SNAP has dedicated but limited
funding for employment and training.
270
Some housing assistance programs have a Section 3
requirement, which mandates that PHAs must use a portion of their federal funding on employment,
training, and other opportunities for certain residents and community members.
271
With regard to
Medicaid, federal law prohibits states from using federal funds for work supports such as child care or
transportation services.
272
To date, state Medicaid work requirement demonstration projects
273
spend
and do little to prepare people for and connect them to work and wraparound supports.
274
While CMS recommends that states carry out Medicaid work requirements through programs that have
some existing labor market-oriented infrastructure, like SNAP or TANF, this is not likely to mitigate
concerns.
275
New Medicaid work requirements, as they are mandatory, will apply to a much larger
population than in SNAP, which could strain its already under-resourced training and support programs,
as most of these states are not significantly increasing their funding outside of Medicaid.
276
Researchers
at the Commonwealth Fund have concluded that they “are not well designed to help people get jobs or
improve health and are more likely to lead to a loss of health insurance coverage.”
277
As discussed in further detail later in the paper, work requirements divert substantial state resources
towards administrative efforts, such as tracking compliance, which leaves few if any resources for work-
supporting services. States have claimed they will use workforce development funding under the
Workforce Innovation and Opportunity Act (WIOA) to fill in the gaps, but WIOA is already inadequately
funded and is not structured to scale up and help a new population that faces many barriers to
employment.
278
(WIOA also has a long history of struggling to help workers with the greatest barriers,
including TANF recipients who have work requirements.)
279
As a result, work requirements will likely
further burden under-resourced workforce development programs.
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Work Requirements Fail to Reduce Poverty & May Even Increase Poverty by
Weakening Foundational Programs
A robust body of evidence shows that conditioning foundational program participation on harsh work
requirements is not an effective strategy for reducing or mitigating poverty. Evidence from work
requirements in TANF
280
and SNAP
281
suggest that work requirements may result in the deepening or
increasing of poverty.
282
This is for two major reasons: many subject to the rules are in low-wage jobs,
and some are unable to find work due to serous or multiple barriers to employment. The
aforementioned study of AFDC-era waiver demonstrations in 11 states indicates that poverty decreased
by 2.1 percent among recipients subject to work requirements, though deep poverty also increased by
2.9 percent.
283
A follow-up study found that the poverty reduction effects that did occur were short-
lived and did not continue in the long run.
284
Additionally, the study concluded that the program did not
result in “systematically greater income or reduced poverty for AFDC recipients,” and “did not generally
improve the economic wellbeing of the welfare recipients.”
285
Some point to the substantial decrease in TANF participation since its inception,
286
and the initial
decline in poverty rates from 1996 to 2001,
287
as indicators that work requirements are effective at
increasing employment and reducing poverty.
288
However, even as TANF participation has dropped,
poverty among families has not. Even the initial decline in poverty came about during a strong economy,
and the expansion of other programs, such as the EITC, likely contributed to the reductions.
289
While a
decline in TANF caseloads could be seen as a sign of effectiveness if it corresponded with a decrease in
poverty among people leaving TANF (voluntarily or involuntarily), this has not been the case. Rather, the
evidence suggests that TANF just became out of reach for most families in need.
Even participants in programs with work requirements who do find work face the problem of being
phased out of benefits they may still need. The original AFDC waiver study found that participants who
found jobs were still below the poverty line because their earnings did not increase enough.
290
For many
of the enrollees who did earn enough, they were phased out of receiving benefits, as their incomes rose
above program eligibility levels.
291
The partial or full loss of benefits thus offset many of their gains from
employment and earned income.
292
Studies on the impact of SNAP work requirements found that while
employment increased among those subject to work requirements, their incomes remained below the
federal poverty line.
293
Though evidence from work requirements in housing assistance demonstration
programs is mixed, a clear takeaway is that work requirements did not boost families’ incomes enough
to allow them to transition out of these programs.
294
Deep Poverty is Likely to Rise as a Result of Work Requirements Weakening
Foundational Programs
Research links work requirements in programs that serve as lifelines to increases in the number of
people experiencing deep poverty and income inequality.
295
Certain populations, such as single-parent
households
296
and individuals with multiple barriers to employment,
297
may be at particular risk of
experiencing deep poverty due to work requirements.
The aforementioned study of 11 AFDC-era work requirement pilot programs evaluated which strategies
had the most success in reducing poverty rates for single-parent participants.
298
The study found that
adding work requirements to cash assistance programs increased deep poverty.
299
In TANF, data from
the subsequent decade and a half have revealed additional harmful results. Research shows a rise in
both deep and extreme poverty, defined as living on “$2 or less, per person, per day,”
300
since the
beginning of the program (see Figure 8). A number of other studies confirm these findings, showing that
deep poverty rates have risen sharply since the advent of TANF.
301
Unsurprisingly, the number of
households with children experiencing extreme poverty has ballooned, from 636,000 in 1996 to 1.65
million in 2011.
302
The rise in deep poverty due in part to work requirements
303
under TANF has particularly affected
children. From 1995-2005, the number of children in deep poverty rose from 1.5 million to 2.2 million.
304
For children in single-parent households, particularly those raised by single mothers disconnected from
the labor market, the percentage in deep poverty more than doubled, from 2.8 percent in 1995 to 5.8
percent in 2005.
305
A 2015 Center on Budget and Policy Priorities study found similar results, showing
that “in more recent years, a significant number of single-mother families appear to have been made
worse off and to have higher deep poverty rates.”
306
In the pre-TANF era, the increase in deep poverty occurred because many participants were unable to
find jobs and experienced longer-term financial instability.
307
In the years following the creation of TANF,
factors including work requirements contributed to the continuation of the trend, as the shrinking
availability of TANF benefits aided in increasing extreme and deep poverty.
308
The new work
requirement proposals for similarly last-resort programs are likely to replicate and potentially even
magnify these harmful effects, due to present-day low-wage labor market characteristics. Some states
are already showing early evidence of such effects. For example, in the year following the
implementation of additional SNAP work requirements in Kansas, 80 percent of SNAP participants with
jobs had incomes at or below the poverty line.
309
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Figure 8. Number of people in deep poverty has increasingly exceeded number of people served by
TANF following 1996 welfare law
Number of AFDC/ TANF participants vs. number of people with household incomes below 50% poverty
level, 1975-2011
Work Requirements Lack Important Guardrails for States
Policies to take away benefits from individuals who are unable to meet a work requirement generally
lack features that would hold states accountable for providing adequate support and communication to
participants so they can fulfill the requirement. This is a recipe for ineffectiveness. For example, it is
widely documented that states often improperly administer work requirements, with high rates of
error.
310
Many times staff do not have adequate training or may also face a time crunch.
311
Multiple
studies have found state TANF sanction processes to be problematic and error-filled. For example, a
study found that in Tennessee, roughly 30 percent of all TANF sanctions “were imposed in error.”
312
Such errors can be clerical or result from miscommunication or a lack of communication,
313
such as a
failure to receive notices, among other reasons.
314
Since state and local offices determine which
participants are subject to new work requirements, as they do for TANF, additional opportunities for
error abound.
315
Other studies have found that many individuals who should receive exemptions do not
and are instead sanctioned.
316
Layering on additional requirements increases the risk of administrative errors even if participants
complete their part of the process correctly. For example, even if a participant follows the guidelines
exactly to document their work activities and meet the eligibility standards, a mistake on the agency’s
side in reporting the worker’s hours (for example, due to lost paperwork, computer errors, bureaucracy,
or other administrative errors) may result in the worker losing their benefits. There are documented
cases of this occurring in TANF in states.
317
States are not penalized for these errors and the onus of
challenging them falls on the participant, as do the consequences from the mistake.
States also lack accountability when it comes to communicating about the process of fulfilling work
requirements. An empirical assessment of TANF sanctions found that for a good proportion of
sanctioned recipients, information about their status was lacking and the rules associated with
sanctioning were unclear.
318
According to the Urban Institute, such a trend seems to be continuing with
the Medicaid work requirements that have been implemented in 2018: “only about half the states offer
any information on whether assistance would be available to beneficiaries to help them meet the work-
related requirements” in their Medicaid waiver applications, let alone provide such assistance
themselves.
319
In Arkansas, a lack of reliable internet access and public awareness may have contributed to the low
compliance with the new rules.
320
Recent interviews with Arkansans subject to Medicaid work
requirements detailed cases where enrollees reported never having heard of the new work
requirements, concerns about transportation access to get to jobs, and lack of awareness about when to
report work hours.
321
CMS has no requirement that states reach out to beneficiaries in person or by
telephone to explain the new work rules. Program administrators in Arkansas did attempt to contact
enrollees who likely needed to document their work hours, but only successfully reached about 20
percent of them.
322
These initial findings indicate that insufficient communication to the public and
limited supports for affected participants may be behind massive coverage losses, rather than failure to
meet new standards.
The kind of robust evaluations of work requirements that can give states clear information about these
types of problems arising during the implementation process is not required by statute. Absent
widespread pushback, this is likely to result in states not implementing evaluations and or being held
accountable for outcomes. For example, in Wisconsin, which has expanded work requirements for
SNAP, there was evidence that work requirements have been harmful for recipients, but former
Governor Scott Walker declined to implement a formal evaluation to confirm these findings.
323
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Revoking Access to Work-Supporting
Programs Due to Rigid & Impractical Work
Requirements is Inefficient
ork requirements are inherently burdensome for all parties. Decades of experience with
TANF and similar programs show that introducing new work requirements generates costly
and onerous work for participants and state administrators, and consumes critical state
resources.
324
This section explores how inconsistencies in the design and implementation of work
rules,
325
increased administrative burdens, and intrinsic complexity will lead to major inefficiencies. The
section also discusses how the new work requirements will lead to inappropriate eligibility
determinations, widespread reductions in program caseloads, and chilling effects. Lastly, the section
outlines how some states may not fully appreciate the adverse macroeconomic consequences of
implementing work requirements. All of these factors will cause further economic and social harms,
both in the short and long-term.
States Make it Difficult to Comply with Work Requirements
Administrative requirements—especially unrealistic expectations for documentation, verification, and
tracking—in combination with minimal accountability for states
326
make work rules needlessly difficult
for participants.
327
In states that have already implemented work requirements for SNAP
328
and
Medicaid,
329
enrollees have experienced substantial technical and material barriers at every stage of the
process, from application to reporting.
WORK RULES IMPOSE CUMBERSOME REQUIREMENTS ON PARTICIPANTS, REGARDLESS OF
EMPLOYMENT STATUS
Work requirements often paint participants with a broad brush that does not consider the different
needs of program participants. This is due to the expansive and indiscriminate nature of work
requirements, which can lead to a number of efficiency issues (such as red tape, wait times, and
technological difficulties) affecting both individuals and states.
330
As a result, work requirements affect
all program participants, whether they are already working or typically not expected to work. For
example, certain proposals for Medicaid would require all working-age enrollees—regardless of
employment status—in participating states to comply with cumbersome reporting obligations.
331
Often, providing initial documentation for program enrollment, and demonstrating ongoing compliance
just to maintain benefit receipt, already involves a number of challenging steps for participants,
including paperwork; in-person appointments;
332
and other burdensome, time-intensive obligations.
333
The new proposed work requirements create more difficulties and opportunities for error. For example,
even after eligibility is determined, participants must regularly submit documentation of their hours
worked—in some cases from multiple jobs—to comply with work requirements.
334
Research suggests
that requiring such intensive and frequent documentation to maintain coverage greatly increases the
risk for participants—even those who are working enough hours to comply—to fall out of compliance
and lose their benefits.
335
Many working participants may have difficulty identifying hours worked each
week due to the temporary or informal nature of their employment.
336
In the case of Medicaid work
requirements, states like Kentucky are requiring family caregivers to keep logs or engage in other
W
record-keeping practices to document caregiving hours.
337
Such a requirement compounds the
challenges many caregivers already face.
338
Navigating the different rules and processes across programs can also be challenging and time-
consuming for participants. The process of complying with reporting requirements may include waiting
for appointments and taking time off for in-person meetings with a caseworker.
339
Additional
administrative burdens related to work requirements may also increase backlogs in processing
paperwork, especially if states change the required number of work hours over time.
340
Stringent cutoffs
for reporting may also harm participants—Arkansas, for example, has implemented a policy requiring all
hours worked for the previous month to be reported no later than the fifth of each month.
341
If a worker
is unable to fully report their hours by the fifth but attempts to report hours after that date, the hours
would not be counted toward the required monthly hourly minimum.
342
Other workers may experience barriers to documenting their hours through internet or telephone
reporting.
343
Online reporting poses a serious barrier to compliance for the significant number of low-
income people in the U.S. who lack reliable internet access. In Arkansas, the state with the lowest
household internet access rate in the country, 20 percent of enrollees subject to work requirements lack
internet access in their homes.
344
Despite this, when the state implemented work requirements for
Medicaid, it limited participants to online-only reporting. So far, more than 18,000 people have lost their
health coverage in Arkansas.
345
Even when participants can get online, online-only reporting presents a
host of obstacles for participants. In Arkansas, according to the Urban Institute, “reporting work
activities each month requires at least 13 steps, and documenting exemptions requires at least 11
steps.”
346
Participants have reported that the online portal was difficult to access and use on mobile
phones, even though that was the primary mode many participants used.
347
The portal also closed at
9:00 p.m. each day for maintenance, further limiting participants’ access.
348
Arkansas ultimately
experienced widespread backlash to its online reporting requirements (as of January 2019, the state is in
the process of adjusting them in response).
349
Nevertheless, states are likely to follow Arkansas’ lead in
using online systems as the primary means for enrollee documentation.
Navigating such hurdles can result in devastating consequences for participants, and it can be difficult
for participants and program administrators to adjust if something goes wrong. Studies show that
“failing to submit paperwork—even when participants are working and meeting the work
requirements—will cause people to lose their Medicaid coverage.”
350
For states that choose to
implement work requirements in Medicaid, the state program will have to develop a new monitoring
system to verify participation in work or other qualifying activities (unless it relies entirely on a state’s
TANF program for this, which is inadvisable—see section, “States are Ill-Equipped to Administer Work
Requirements”). The TANF experience also provides insight into some potential pitfalls of such intensive
tracking. Despite some praise of the 1996 law that created TANF, by the time it was reauthorized in
2005, many had concluded that states were engaged in widespread erroneous or problematic tracking
of participation by TANF recipients.
351
Even a relatively “light touch” initial approach to verification in
Medicaid waivers may see similar intensification over time, leading to additional paperwork for
participants and more hassle for their employers. No matter how the requirements are implemented,
many people are likely to be sanctioned and lose benefits due to burdensome documentation and
reporting processes, rather than actual noncompliance.
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Unworkable & Unwise | 43
PARTICIPANTS BEAR THE BURDEN OF NAVIGATING UNRELIABLE & UNEVEN EXEMPTION
PROCESSES
States have some latitude when it comes to exempting populations from new work requirements in
SNAP, Medicaid, and housing assistance. There are multiple forms of exemptions, depending on the
work requirement and the program (as discussed in Box 2). For example, for Medicaid work
requirements, the Trump Administration has delegated all eligibility determination to the states. (While
the CMS guidelines contain suggestions for exempted populations, it is up to states to decide who is
covered and who is not.) Several state proposals have carved out other exemptions for populations
facing significant barriers to employment, such as people with disabilities, caregivers, students, people
who have experienced Domestic Violence/Intimate Partner Violence (DV/IPV), and federally recognized
tribes.
352
,
353
,
354
,
355
In practice, however, exemptions fall short of protecting these populations from
losing their benefits—and of alleviating any of the administrative burden for enrollees and states.
356
Requiring participants to apply for exemptions further burdens already overburdened and financially-
stressed populations. For all involved, the process is likely to be costly and time-consuming, and the
exemptions likely to be unevenly and unpredictably applied (see Figure 9 and appendices for detailed
descriptions of state policies).
Several factors contribute to the disparate application of exemptions within and among states. Using
disability as an example, across the board, it is unclear what “counts” as a disability for the purposes of
work requirements.
357
Many people face significant barriers to work due to a work-limiting disability or a
severe or chronic illness that does not meet the formal definition of a disability in their particular state
or may not be labeled as a disability by their local benefits office. However, they still would be subject to
work requirements in Medicaid.
358
In addition, state definitions of various eligibility thresholds (such as
disability) vary,
359
and the often-broad language in the policies leaves much room for discretion.
360
In
Kentucky’s Medicaid work requirements, “able-bodied” people would be required to work, but
individuals deemed “medically frail” would not
361
and there is no clear standard for making these
determinations.
362
The ambiguity in the details of these policies may lead to inconsistent screening or harmful
determination practices. Research on TANF suggests that individuals “with severe but temporary
disabilities may not be not exempt from a work requirement and may lose benefits, despite facing
substantial barriers to employment as a result of their health needs.”
363
States have varying screening
processes for workers with disabilities. As a Mathematica report notes, “few TANF agencies have
comprehensive processes in place to identify recipients living with a disability, although some agencies
do routinely screen for mental health conditions or learning disabilities.”
364
It is therefore not surprising
that TANF participants who were sanctioned for not meeting a work requirement are more likely to
have a disability than non-sanctioned participants.
365
A study of adults who exited TANF without finding
employment found that over 41 percent reported having poor mental or physical health.
366
Since states
have had little time to build in consistent processes before rolling out new work requirements in
Medicaid and SNAP, screening procedures are likely to be even more unpredictable and inconsistent.
They may also lead to participants with disabilities being incorrectly mandated to work and eventually
losing their benefits.
Figure 9. States employ varying work requirement rules
Waivers and policies for SNAP, Medicaid, and housing assistance by state as of January 2019
Working Paper
Unworkable & Unwise | 45
The lack of specificity in CMS guidelines about other exemptions have resulted in significant
inconsistencies in policies by state. Some states, such as Arkansas, have broadly exempted parents,
while other policies only exempt parents with children below a certain age.
367
Some states are
exempting students or allowing class hours to count towards the requirement, while others are not.
368
Even within states where students are technically exempt from work requirements or can count their
coursework as work, inconsistencies may still arise, due to inefficient exemption determination and
reporting requirements.
369
TANF again provides an instructive example: it has been particularly
challenging for students to combine school or training with work to meet TANF requirements.
370
,
371
If a
state chooses to adopt TANF-like rules for counting education and training towards the requirement,
students receiving Medicaid may find themselves in a similar position. (See Box 2 for additional
information about exemption inconsistencies.)
Implementing exemptions consistently and fairly is a difficult task for administrators of any program.
372
It takes time and resources to screen and verify each enrollee for exemption eligibility and to respond to
appeals. A few states have taken steps that might appear to streamline the process for certain
participants. For example, some states automatically exempt those who receive or apply for disability
benefits (rather than invoking a cumbersome case-by-case assessment to determine whether a chronic
health condition or mental health issue are sufficient to warrant an exemption).
373
Arkansas is using a
data match system to automatically exempt the bulk of participants who qualify for an exemption.
However, even under this system, some people will still have to apply for an exemption, which means
barriers such as a lack of internet access may still affect them.
374
Such policies still fail to address the fact
that the burden of proof is being placed on already-struggling people, and that many are likely to slip
through the cracks and unfairly face work requirements, particularly people with disabilities who are
outside of SSDI and SSI and people with prohibitive economic disadvantages.
Furthermore, studies have found that each additional piece of paperwork leads to fewer eligible
individuals receiving the benefits they need.
375
The initial loss of social supports can make it hard to
become eligible for these benefits again, as it becomes harder to work without the supports
themselves.
376
Given the relatively high levels of employment among Medicaid recipients, especially in
Medicaid expansion states,
377
the initial waivers may appear to affect a modest number of Medicaid
enrollees. Under the CMS guidance, however, states could require a large number of adults to
document their current employment or other reason for being exempt.
378
Due to the administrative
burden of this documentation,
379
most people who would lose coverage actually meet the work
requirements, but would lose their eligibility because of how difficult it is to understand this
bureaucratic process and correctly complete it.
380
,
381
Work Requirements Are Burdensome for States & Their Limited Resources
The red tape from work requirements negatively affects states.
382
Even if the aforementioned
implementation issues were resolved, the required verification, documentation, and enforcement still
would make work requirements an inefficient and counterproductive use of limited state resources.
Existing programs with work requirements have shown that the added bureaucracy is cumbersome and
costly for state administrators, and diverts limited resources.
383
Some proponents of work requirements
may view participants’ subsequent loss of benefits—due to being unable to comply—as a net gain for a
state, due to reduced program spending. However, research suggests that the “penny wise, pound
foolish” nature of work requirements will not save states money in the long run.
STATES ARE ILL-EQUIPPED TO ADMINISTER WORK REQUIREMENTS
For a number of reasons, both fiscal and structural, states are ill-equipped to administer new work
requirements. Evidence from programs with existing work requirements illustrates some of the
challenges associated with administering work requirements. Tracking participation for all enrollees
requires extensive administrative resources and capacity, as does conducting eligibility screening and
developing a network of employers and employment training providers.
384
Research on SNAP and TANF
requirements shows that caseworkers spend considerable time monitoring participants’ work-related
activities.
385
States, however, lack the necessary infrastructure for doing this tracking in Medicaid and
housing assistance programs, and on an exponentially larger scale than currently in SNAP;
386
creating the
infrastructure for these programs would require a massive diversion of resources.
Medicaid has never included a work requirement,
387
nor was it set up to function as a work program.
While it supports work
388
indirectly, its statutory purpose is to provide health coverage.
389
The 2018 CMS
guidance related to the waivers encouraged states to lean on and build upon existing infrastructure in
TANF or SNAP related to work requirements and reporting.
390
To the extent that a state chooses to
administer Medicaid work requirements through TANF, it is unclear how the state would avoid
replicating many of the systemic challenges experienced by TANF participants, particularly for enrollees
with serious or multiple barriers to work.
391
A state could choose to develop the necessary infrastructure
within Medicaid or another program, although states are ill-equipped for the task.
392
(While states must
automatically consider people who are satisfying TANF and SNAP work rules as also compliant with
Medicaid work rules,
393
participants may still have to provide separate documentation for each of the
different programs, which can compound their administrative burden.) SNAP and housing assistance
face similar structural limitations for administering work requirements or coordinating with another
agency to do so.
Research suggests that each option presents significant challenges for states. First, coordinating multiple
agencies, particularly given the lack of directives and the limited time period in which they are often
developed, requires substantial resources. As SNAP and TANF services are typically co-located, it could
potentially be a lighter lift to coordinate work requirements for SNAP participants through TANF.
394
But
the local administration of housing assistance programs likely would prevent connections with state
administered TANF and SNAP systems.
395
Public Housing Authorities likely lack the resources to develop
their own systems for work supports.
396
Second, public assistance offices—which can be administered at
the state, county, or local level depending on the state—are already understaffed and under-resourced.
Work requirements impose additional obligations on capacity that are likely to further overwhelm and
undermine offices,
397
especially considering the need for up-to-date technological systems or systems
that can coordinate with each other.
398
As a result, neither the use of existing infrastructures nor the creation of new ones is likely to adequately
service the substantial rise in administrative functions and demand on organizational capacity. For
example, a state would need its own approach to determining which applicants or recipients have
conditions or situations that merit an exemption and which do not.
399
An administering agency may
choose to rely on requiring up-front job search and receipt of disability benefits as a proxy for being
unable to work, rather than engaging in serious assessments of a person’s capacity to work. This process
may incorrectly penalize individuals who face significant barriers to work due to a work-limiting
disability or a health condition.
400
State workforce development entities are similarly likely to be
overwhelmed by the influx of Medicaid, SNAP, and housing assistance enrollees into their training and
job placement programs,
401
as discussed earlier in the paper.
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Unworkable & Unwise | 47
PROPOSALS THAT TAKE BENEFITS AWAY FROM PEOPLE WHO DO NOT MEET A WORK
REQUIREMENT MAY INCREASE COSTS FOR STATES
A growing body of research suggests that work requirements in foundational economic security
programs may be an unproductive use of scarce or restricted resources.
402
Due to the inherent
structural inadequacies outlined previously, work requirements generate sizeable net costs for states.
403
States considering work requirements should weigh potential short- and longer-term economic
outcomes of implementing and enforcing them. An estimate of the potential impacts in Missouri, a state
exploring work requirements for Medicaid, found that as just a fraction of “enrollees would be subject
to work requirements, implementation costs may outweigh any potential savings.”
404
Similar analyses of
the potential costs of implementing new work requirements in SNAP and housing assistance programs
have drawn parallel conclusions.
405
Because states are ill-equipped to enforce work requirements, implementation often requires
substantial upfront investment. Kentucky, for example, expects to spend about an additional $370
million in the first two years of implementation on administrative costs for Medicaid waivers.
406
Informational technology changes and growth and training of administrative staff are needed to track
and enforce compliance with the requirements.
407
For changes that are supposed to affect a fraction of
Kentucky’s Medicaid population (less than 200,000 of the state’s 1.4 million enrollees), they are
commanding disproportionate financial resources.
408
,
409
It is unlikely that these costs, which could
amount to “thousands of dollars per beneficiary,”
410
will be offset by savings, because even if
participants do find work, their earnings are unlikely to increase enough to allow them to transition into
employment sufficient enough to afford private health coverage.
411
In addition to startup costs, states must devote considerable resources to ongoing verification and
related enforcement activities. For every participant, states must track and record each hour of work,
whether through their own already-limited staff or by hiring contractors.
412
Since many exemptions
granted by states are temporary, states have to re-evaluate and document them repeatedly.
413
There is
evidence that such efforts are not only costly, but inefficient, as states can end up spending more
resources and administrative time tracking hours than providing essential work-supporting services.
414
,
415
Again, there is little evidence that states will recoup these costs in the long-term.
Even though work requirements would spur sizeable new and ongoing spending obligations for states,
as mentioned earlier, states have not been required to pair such efforts with spending on services and
supports that would help participants find and maintain employment. With limited resources likely
strained by new work requirements, states may choose not to create new employment and training
programs, especially if they are not required to do so. In fact, many new work requirement proposals
“have not included additional funds to provide employment programs and services.”
416
Even in states
that have allocated funding for employment services, state officials have indicated that funding is too
low and much less than funding allocated to track compliance.
417
Under the proposed 2018 House Farm
Bill, states would have been required to offer employment, training services, and case management that
would meet the 20 hours/week standard to all participants subject to work requirements. However,
there is evidence to suggest that the bill’s $1 billion per year workforce development funding increase—
financed through benefit cuts—would be inadequate to cover the cost of providing employment and
training (E&T) services. An estimated 3 million additional E&T slots would be needed by 2021 and the
new funding would amount to only about $30 per month per person, which likely would be insufficient
to cover the need.
418
In fact, the Congressional Budget Office (CBO) estimated that by 2028, state
governments would be unable to meet the new E&T requirement.
419
As a result, by 2028, more than 1
million people would lose SNAP as a result of these provisions.
420
Implementing new work mandates is also likely to result in states incurring substantial indirect costs.
First, research suggests that Medicaid work requirements will ultimately lead to increases in
uncompensated care costs for states.
421
A substantial body of evidence has documented the reductions
in uncompensated care for people who are uninsured, due to Medicaid expansions under the ACA in
states.
422
As work requirements will result in people losing coverage, such gains are likely to reverse.
Estimates of the impact in Kentucky offer a compelling illustration of such effects: implementing work
requirements in Medicaid would result in approximately 108,000 to 118,000 Kentuckians losing
coverage; hospital uncompensated care costs are also expected to double, “leading to significant
declines in operating margins, especially for safety-net hospitals.”
423
Second, work requirements may
harm state economies. Medicaid expansions have demonstrated substantial short- and even long-term
benefits to participants and society at large. One study looking at longitudinal data found that for
children whose eligibility increased due to expansions in Medicaid and CHIP, by age 28 they had paid
more taxes and had lower EITC payments; the women also had greater cumulative wages.
424
As a result,
the government is able to recapture “much of its investment over time in the form of higher future tax
payments.”
425
Because work requirements are likely to lead to coverage losses, however—and research
demonstrates that when parents do not have access to health care, their children are also less likely to
receive it
426
—states that choose to expend resources on enforcing work requirements would forgo any
similar return on investment.
WORK REQUIREMENTS FAIL TO CONSIDER MACROECONOMIC RAMIFICATIONS FOR STATES
These new proposals that take away foundational assistance from people who do not meet work
requirement policies have paid little attention to the numerous economic challenges they present for
states and the resulting inefficiencies. In an economic downturn, employers and consumers limit
spending. This leads to more job loss and reduced revenues. One of the ways the federal government
helps the economy weather the storm is by stimulating more private and public spending at both the
national and state levels. Programs with countercyclical designs, such as UI, SNAP, and Medicaid, do this
automatically. These programs directly and indirectly give participants more money to spend, and as
people with low incomes are especially likely to spend that money to meet their basic needs, it goes
directly back into the economy, supporting the recovery (see Figure 10). As a result, these programs act
as moderating forces for the depth and breadth of any downturns that occur, helping to mitigate harm
to families and communities and accelerate economic recovery.
Working Paper
Unworkable & Unwise | 49
Figure 10. Medicaid & SNAP responded more robustly to the Great Recession & its aftermath than
TANF
Number of participants (in thousands) for Medicaid, SNAP, TANF, & number of people unemployed, FY
2005-2017
Policies to take benefits away from people who do not meet a work requirement, on the other hand,
lack this important feature and are actually pro-cyclical. Evidence indicates that programs with
automatic stabilizers
427
typically start expanding in response to increased need long before a downturn
is officially recognized.
428
Without any type of automatic countercyclical policy, states are set up for a
cycle of reliance on temporary, discretionary fiscal policy fixes every time there is a downturn.
429
Ultimately, work requirements would exacerbate the negative effects of a downturn, such as rising
unemployment, increasing economic hardship, and shrinking output.
Research also suggests that even in periods of economic growth, work requirements make little sense
for state economies, and would even result in a net loss of funds.
430
For Kentucky and Arkansas, as with
all states that have chosen to expand Medicaid, the federal government bears the lion’s share of
Medicaid costs for expansion enrollees.
431
,
432
By opting to utilize Section 1115 waivers to introduce work
requirements in Medicaid, both states are forgoing substantial federal funds in exchange for extremely
modest state savings, if any. An estimate found that in 2020, Arkansas will lose between $220 million
and $340 million in federal dollars.
433
In contrast, the state will save only $25 million on its own
spending.
434
The benefit to Arkansas taxpayers is miniscule, at an estimated $8 to $13 per capita each
year, and the state will be giving up the equivalent of nearly 5 percent of its total tax revenues in federal
funding.
435
Kentucky is in a similar situation. An estimate by The Commonwealth Fund found that by 2021, when
the work requirements are proposed to be fully in effect, Medicaid enrollment will plunge, and as a
result the state will lose $680 million federal dollars annually.
436
The estimate noted that the subsequent
annual loss of federal funds “will be of a magnitude similar to the state losing its entire federal highway
program funding each year.”
437
The state will reduce its own related expenditures in 2021 by just $120
million.
438
As with Arkansas, the immediate savings to Kentucky taxpayers will be small. According to the
estimate, “at a per-capita level, the net-of-taxes reduction in federal funds will amount to about $150
per Kentucky resident … the savings in state tax obligations will be just $28 per Kentucky resident.”
439
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Policies to Take Benefits Away from
Recipients Who Do Not Meet a Work
Requirement Are Inequitable
andating participation in work or related activities to receive Medicaid, SNAP, or housing assistance
would limit these important supports in harmful and (in the case of Medicaid) unprecedented ways.
These new work rules are symptomatic of a broader, systematic strategy of gatekeeping, shrinking, and
undermining the system of public benefits that supports struggling individuals and families.
This section discusses how the harmful consequences of new work rules disproportionately
fall on people and groups who face systemic oppression and will increase social and economic
inequities by concentrating harms on the most vulnerable and disadvantaged. The section also
briefly outlines some of the likely impacts of those burdens.
Work Requirements Disparately Harm Groups Who Experience Systemic
Oppression
The burdens and harms of introducing new work requirements to Medicaid, SNAP, and housing
assistance programs disproportionately fall to low-income people who are already held back by racism,
sexism, ableism, heterosexism, and ageism. People who experience discrimination in the workforce,
inequities in public benefits systems, and barriers to employment specific to their identities will likely
find it more difficult to meet stringent work requirements. And due to already higher poverty rates,
when their benefits are taken away these groups are more likely to experience severe harms. This
section briefly outlines how work requirements disparately impact people with disabilities, people of
color, women, LGBTQ people, and older workers. Many people belong to two or more disadvantaged
groups, which compounds the barriers they face and deepens the harm that work requirements are
likely to cause. For example, the intersection of race, gender, age, and disability can result in a higher
risk of losing health coverage, even for people who are working. People with disabilities are more likely
to be in part-time jobs where they may not meet the minimum work hour standards needed maintain
health coverage.
440
Women have slightly higher rates of disability than men and will likely be
disproportionately impacted by a loss of health coverage as the majority of adult Medicaid enrollees are
women.
441
PEOPLE LIVING WITH DISABILITIES & CHRONIC HEALTH CONDITIONS
Work requirements are likely to cause disproportionate harm to people with disabilities and their
families.
442
People with disabilities or chronic health conditions are more likely to experience poverty
than people without them. Working-age people with disabilities are three times more likely to live in
poverty than working-age adults without disabilities.
443
Additionally, 61 percent of working-age adults
with disabilities earned incomes below 200 percent of the federal poverty line in 2013.
444
Discrimination
in the workforce against people with disabilities or chronic health conditions
445
,
446
and other barriers to
employment increase the chances that they will not be able to meet new work requirements.
447
According to one study, SNAP participants who would be subject to new work requirements proposals
identified health challenges (including disabilities) as the primary reason for not working.
448
Similarly, of
the estimated 11 million at risk of losing their Medicaid benefits if work requirements were imposed
M
nationally, data indicate that a majority (59 percent) have a serious health condition or live with
someone who does.
449
(The problems with the unclear, inconsistent exemption process discussed earlier
in this paper put people with disabilities and serious health conditions at serious risk of harm from
sanctions.)
450
Without health coverage, people with disabilities or chronic health issues could be at risk
of losing their jobs due to unaddressed health and disability challenges.
451
Many people with disabilities
may need ongoing care. The Center on Budget and Policy Priorities notes that, “[c]overage interruptions
lead to increased emergency room visits and hospitalizations, admissions to mental health facilities, and
health care costs.”
452
PEOPLE OF COLOR
Systemic racial and ethnic discrimination continue to harm people of color, and evidence shows that
taking away health care, food, and housing assistance exacerbates the effects of discrimination.
453
,
454
As
discussed earlier, people of color face prejudice and discrimination in the labor market and workplace,
which can significantly hinder their ability to find and retain adequate employment.
455
Racial inequities
baked into social policy design
456
and bias within benefits administration systems
457
result in even more
inequitable outcomes. Higher poverty rates among African-Americans, Latinos, and AIAN relative to
whites means that communities of color likely would experience greater harm from the loss of health,
food, and housing program benefits.
458
,
459
Evidence from TANF, which provides states enormous flexibility, indicates that states are more likely to
pursue stricter work requirement policies when a greater share of their population is African
American.
460
The 25 states with the lowest TANF-to-poverty ratio, or the share of people in poverty who
receive TANF benefits, are home to 65 percent of the total U.S. African American population (see Figure
11), but a significantly smaller share of the non-Hispanic white population.
461
One such state is
Mississippi, which recently submitted a Medicaid work requirement proposal. With many African
Americans in Mississippi facing high unemployment and poverty rates,
462
introducing new work
requirements could lead to the loss of health coverage for a sizeable portion of the state’s African
American population—many of whom may have already experienced cuts in food assistance from the
reinstatement of SNAP time limits for some adults.
463
Additionally, multiple analyses of benefit sanctions
under TANF find that African-American and Latina women are more likely to be sanctioned than white
women.
464
,
465
These findings demonstrate how caseworker discretion and biases can factor into the
administering of work requirements, thus harming people of color disproportionately.
466
Proposed cuts through work requirement pose unique threats to Native populations. At 28 percent,
AIAN face a poverty rate twice the national average, and many rely on food and health coverage
provided by SNAP and Medicaid.
467
Almost a quarter (24 percent) of all AIAN receive SNAP benefits, and
in some tribal communities, the SNAP participation rates are as high as 60-80 percent.
468
The high rates
of food insecurity among the AIAN populations can in part be traced back to federal polices such as the
Dawes Act of 1887, that stripped American Indians of land they had been inhabiting to make room for
white settler communities.
469
Indigenous peoples were forced to live on land that was less productive
for agriculture, ranching, and/or endowed with fewer natural resources.
470
,
471
,
472
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Twenty-five percent of working-age AIAN
adults, and half of AIAN children participate in
Medicaid.
473
Given the importance of SNAP and
Medicaid in Tribal communities, instituting new
work requirements could result in massive
losses of health coverage and food assistance
and could exacerbate current economic
development challenges on tribal lands.
Compliance and documentation of work
requirements would create undue burdens for
AIANs, many of whom live in remote areas with
high unemployment rates and where 1 in 4
working age adults report having a chronic
health condition that presents a barrier to
subsistence jobs which would be difficult to
document or record to comply with work
requirements.
474
Due to these burdens, some
experts predict that subjecting AIAN
populations to new work requirements in
Medicaid or SNAP would result in many not
participating and ultimately losing coverage.
475
Implementing Medicaid work requirements also
could lead to decreased funding for the Indian
Health Service (IHS), which operates clinics and
hospitals across Tribal lands. Up to 13 percent
of IHS operational funding comes from
Medicaid expansions under the 1976 Indian
Health Care Improvement Act, and would be at
risk of decline under new work requirements
rules.
476
Instituting work requirements may violate
federal treaties and legal agreements that
recognize the sovereignty of Tribal nations.
Concerns about such violations led four states
to seek exemptions for Medicaid work
requirements for Native populations in early
2018.
477
CMS rejected these requests, but
partially reversed its decision in July 2018,
stating that states had “flexibility and discretion
to implement the community engagement
requirements with respect to local tribal
members.”
478
,
479
Still, providing states with
discretion to subject Native populations to work
Figure 11. African Americans are disproportionately
affected by inadequate access to Temporary Assistance
for Needy Families (TANF)
TANF-to-poverty ratios in 50 states and the District of
Columbia, 2017
requirements at all may be in violation of the sovereignty of Tribal nations and jeopardizes their
wellbeing.
WOMEN
New work requirements in Medicaid, SNAP, and housing assistance are likely to worsen existing gender
inequities. Women are more likely to experience poverty than non-women, and poverty rates are
especially high among women of color
480
due to a number of factors. Women make up 55 percent of all
U.S. workers in jobs that pay less than $15 an hour.
481
It is common for low-wage jobs to lack employer-
sponsored health insurance and have unpredictable pay and schedules—all factors that could put low-
income women at risk of losing their benefits or coverage due to work requirements.
482
Medicaid is
critical for low-income women who have limited options for health coverage.
483
In fact, more than 6 in
10 nonelderly, non-working Medicaid enrollees in 2015 were women.
484
Many women gain access to
birth control through Medicaid, which affects key decisions in family planning, educational attainment,
and career opportunities.
485
Women also face barriers to employment related to their gender.
486
For example, women provide the
vast majority of family caregiving, which can limit opportunities to participate in formal employment.
487
The fluctuating and unpredictable nature of caregiving responsibilities can also increase exposure to
financial volatility.
488
While caregivers for the elderly, young children, and family members with
disabilities are often thought to be exempt under the new work requirement proposals,
489
states vary in
their implementation of these exemptions (See Box 2.). Some states may have narrow definitions of who
qualifies as a dependent in need of care.
490
Further, the broad and inconsistent definitions of disability
across states
491
could raise problems of exempting women who provide care for family members with
disabilities.
Women are more likely than men to experience sexual harassment in a low-paid job.
492
This is
particularly true of women of color, who are more likely than white women to experience sexual
harassment.
493
New work requirements could also result in victims of sexual harassment at work being
dissuaded from reporting or taking any other action for fear of having their hours cut
494
and losing their
benefits.
The number of unemployed single mothers without financial support has risen in the past two decades,
in part due to TANF work requirements implemented under the 1996 law that created TANF.
495
By 2016,
there were 2 million more unemployed single mothers than families receiving cash assistance in a typical
month.
496
Single mothers who are disconnected from benefits and employment face several barriers to
employment, such as low education, DV/IPV history, and mental and physical health conditions, among
others.
497
,
498
As a result, the new work requirements could especially impact low-income women caring
for their children.
LGBTQ INDIVIDUALS
About 1 in 5 LGBTQ adults experiences employment discrimination
499
and they are more likely to be
unemployed than non-LGBTQ adults.
500
Transgender adults in particular are three times more likely to
be unemployed than non-LGBTQ adults.
501
The high rates of unemployment among LGBTQ people can
largely be attributed to discrimination based on sexual orientation or gender identity.
502
Imposing work
requirements would not address the discrimination many LGBTQ people are subject to, and could
further undermine the economic security of vulnerable LGBTQ adults.
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Due in part to discrimination and inadequate legal protections, LGBTQ people face higher rates of food
and economic insecurity than their non-LGBTQ counterparts.
503
,
504
As a result, many LGBTQ people rely
on basic assistance programs such as SNAP, where LGBTQ participation is more than twice the rate of
non-LGBTQ recipients.
505
Further, LGBTQ adults with children are 1.6 times more likely to report not
having enough food to feed their families at least once during the year.
506
LGBTQ people, especially
those with disabilities, are also more likely to participate in Medicaid.
507
With already high poverty and
high participation in the programs and discrimination blocking access to steady employment, the LGBTQ
community would likely bear a disproportionate share of the burden of policies taking away programs
that ensure basic living standards.
OLDER ADULTS
A perhaps less obvious population that is at risk of being more severely harmed by new work
requirement proposals is older low-wage workers in their 50s and 60s. The proposed 2018 House Farm
Bill,
508
for example, would have extended strict time limits in SNAP to people aged 50-59. (Currently they
apply to adults between 18-49 years old.)
509
Some of the Medicaid waivers for implementing work
requirements also would put older workers in their 50s and early 60s at serious risk of losing benefits, as
they are more likely than younger people to have chronic health conditions, which in turn may make
employment more challenging without qualifying for an exemption from work requirements (see Box 2).
Evidence shows that age discrimination continues to be a pervasive obstacle in the labor market,
particularly for older women, as described above.
510
Conditioning basic supports on employment increases the chance that such discrimination will result in
additional harm to older Americans. For example, workers age 50 and above (who account for 44
percent of the 11 million individuals who could lose coverage under new Medicaid work requirements)
could face worse health outcomes under work requirements, as health coverage can help enable
employment.
511
According to the Centers for Disease Control and Prevention (CDC), 78 percent of adults
aged 55 and over have at least one chronic health condition,
512
which can pose significant obstacles to
working. One study found that increased food insecurity among SNAP participants aged 55 and over
may be associated with a higher rate of emergency room visits.
513
Older workers of color who face
double jeopardy of health disparities and employment discrimination would be at greater risk than their
white counterparts of the harms from losing health coverage under work requirements.
514
,
515
Other Groups Experiencing Deep Economic Insecurity Will be Disparately
Harmed by Work Requirements
Work requirements are likely to be particularly harmful to specific groups of people who tend to be
vulnerable to some of the worst effects of poverty. This section briefly outlines how work requirements
are likely to affect low-income caregivers, former foster youth, people with criminal justice system
involvement, victim-survivors of DV/IPV, and veterans with disabilities.
LOW-INCOME CAREGIVERS & THEIR FAMILIES
Low-income caregivers and their families are particularly at risk of losing vital assistance for food,
housing, and health coverage due to these new work requirements. Caregivers are more likely to have
low incomes, be women, and be older, but are less likely to have health insurance through a spouse or
job.
516
For many family caregivers of young children, elderly people, and people with disabilities, the
costs and time associated with caregiving significantly affect the kinds of jobs they can work and their
ability to save.
517
While the majority of family caregivers are employed,
518
25 percent report spending 40
hours a week helping relatives,
519
and 60 percent say that caregiving has undermined their capacity to
do their jobs.
520
About 1 in 6 of the country’s 44 million family caregivers reported leaving their jobs
because they could not afford to hire a paid care worker.
521
African Americans and Hispanics spend
more time providing care than their white and Asian counterparts.
522
Further, family caregivers spend 20
percent of their income on average on caregiving activities,
523
with Hispanic and African American
caregivers spending a larger share of their incomes.
524
As a result, financial strain and insecurity persist
among caregivers, especially those working in low-wage jobs.
525
Many caregivers rely on Medicaid for health coverage for themselves and the people they care for.
526
Taking away vital health coverage and placing additional financial, emotional, social, and physical
pressures
527
on caregivers would likely compound the inherent challenges of caregiving. For example,
while Kentucky’s Medicaid waiver allows caregiving for those with a disability to fulfill their work
requirement, it will still require caregivers to provide records detailing their caregiving, which most
caregivers do not currently maintain.
528
As illustrated by this paper’s earlier discussions about exemption
and documentation issues, work requirements will likely further complicate challenges related to
caregiving for low-income populations.
PEOPLE WITH CRIMINAL JUSTICE SYSTEM INVOLVEMENT
People with criminal justice (CJ) system involvement are more likely than the general population to face
poverty, homelessness, unemployment, and poor health conditions, even before arrest.
529
Upon CJ
involvement, these challenging factors often multiply. For example, people returning to their
communities after incarceration are three to six times more likely to be diagnosed with a mental illness
and about 50 percent experience chronic health conditions such as asthma and hepatitis. Accordingly,
sanctions from Medicaid based on work requirements could be especially harmful for returning
individuals who face low employment prospects and high recidivism rates.
530
A study of Ohio adults
enrolled in SNAP and subject to time limits if they were unable to document sufficient hours of work
each month found that more than one-third had felony convictions, which respondents indicated made
it hard to find jobs and pass background checks.
531
Since CJ involvement is associated with low pay and unstable work hours, frequent bouts of
unemployment and job turnover, complying with harsh and rigid work requirements for programs
providing basic assistance is likely to be particularly challenging.
532
On top of the substantial barriers to
employment individuals with justice system involvement face, work requirements will further limit
access to social supports
533
and likely make it harder for individuals with criminal records to work.
534
FORMER FOSTER YOUTH
Youth who have aged out of foster care are at particular risk for harm under the new work
requirements.
535
Nationally, foster youth face high rates of homelessness, as well as low educational
attainment, skill levels, and employment rates.
536
More than 20 percent of foster youth experience
homelessness within one year after emancipation,
537
which can make finding and keeping a job difficult.
Homelessness is more acute among LGBTQ youth, who make up as much as 20 percent of the runaway
and homeless youth population.
538
Among foster youth who are employed, many work in low-paying
jobs without prospects to exit poverty.
539
Further, youth in foster care who have experienced neglect or
abuse have a higher likelihood of becoming involved with the criminal justice system.
540
A study on
newly emancipated foster youth found sizeable rates of involvement with the criminal justice system
just six months after emancipation.
541
Given the many barriers to employment people with criminal
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records face, as outlined earlier, former foster youth with a criminal record may particularly struggle to
attain stable employment.
Additionally, while former foster youth are eligible to receive Medicaid until age 26, this mandate
currently applies to states where they lived while in foster care.
542
Were they to move to another state,
most former foster youth would be subject to adult Medicaid eligibility provisions; only 12 states
currently provide the same coverage for former foster youth up to age 26 from other states.
543
Under
these conditions, many former foster youth could be subject to work requirements and risk losing health
coverage. Loss of health coverage could result in deep harm for former foster youth, who experience
physical health conditions, like asthma and obesity, at twice the rate of non-foster care youth
544
and
behavioral health challenges
545
at three times that of non-foster care youth.
546
VICTIM-SURVIVORS OF DV/IPV, TRAUMA, & VIOLENCE
People who have experienced trauma, DV/IPV, or other types of violence are also particularly at risk of
being harmed by the new work requirement proposals. Exposure to trauma and violence can lead to
mental and physical health conditions that may limit one’s ability to participate in the labor force.
547
,
548
,
549
In particular, exposure to traumatic experiences during childhood has been linked to higher
incidences of low work performance in adulthood, as well as financial problems.
550
Yet, in its policy
guidance, the federal government placed no explicit requirements for states to include DV/IPV
exemptions in designing their work requirement demonstrations.
551
The CDC have argued that
strengthening economic supports is a key strategy for preventing DV/IPV,
552
but the lack of exemptions
could put survivors of domestic violence at risk of losing crucial health care and services, pushing
financial security further out of reach, and likely putting more people at risk.
VETERANS WITH DISABILITIES
Veterans with disabilities and health challenges who do not qualify for disability insurance, or who the
Department of Veterans Affairs (VA) does not label “100 percent disabled,” may also be at risk of losing
benefits under these new work requirements.
553
About 10 percent of non-elderly US veterans use
Medicaid, and of that share, 40 percent rely on Medicaid as their only source of health coverage.
554
Among this group of veterans, 54 percent have a disability, 42 percent have two or more chronic health
conditions, 11 percent have severe mental illness, and 12 percent have a substance use disorder.
555
As a
result, veterans with mental health conditions that do not meet disability insurance or VA guidelines
likely would face the difficulties of either fulfilling work requirements or proving their need for
exemption.
556
Moreover, the job and skills training programs provided by the VA may not constitute
sufficient hours to meet the minimum required under various work requirements proposals.
557
Work Requirements Are Likely to Harm People, Families, & Communities
Struggling the Most
Taking away benefits from people who fail to meet new work requirements undermines access to basic
assistance for the people who face the most barriers to financial security, such as those with limited
education and unstable housing. Almost a quarter (24 percent) of Medicaid enrollees who would be
subject to work requirements have less than a high school education.
558
SNAP recipients who are not
raising children and do not have a work-limiting disability have similar rates of education.
559
A study of
SNAP participants subject to time limits in Ohio found that many experienced unstable living situations,
many had limited telephone service, more than 40 percent lacked access to reliable transportation, and
60 percent lacked a valid driver’s license.
560
Implementing new work requirements is likely to lead to a
series of adverse effects on enrollees, their households, and their communities. In fact, work
requirements are likely to harm struggling people the most, and lead to a variety of negative outcomes,
including:
• Lower well-being for families and children, especially for families involved with the child welfare
system
• Increased poverty and deep poverty
• Negative physical and behavioral health outcomes
• Communities with fewer resources
DAMAGE TO WELL-BEING OF FAMILIES & CHILDREN
Losing vital food, housing, and health benefits due to work requirements is likely to be destabilizing for
low-income families with children. Under recent Medicaid, SNAP, and housing assistance proposals,
millions of adults with children would be subject to work requirements, which could have adverse
effects on child well-being. Across programs, any reduction in benefit that reduces total household
income is likely to affect children in particular.
Medicaid & SNAP Work Tests Will Undermine Child Health & Development
Among states that did not expand Medicaid, adults with children will be the main target of work
requirements, since childless adults are generally not eligible for Medicaid.
561
Research has shown that
when parents lose Medicaid coverage, their children are also more likely to be uninsured and the family
is likely to face financial insecurity.
562
,
563
Children with uninsured parents could lose access to full and
preventative health services, such as hearing and vision screenings under Medicaid’s Early Periodic
Screening, Diagnostic and Treatment (EPSDT) benefit,
564
which could result in negative health outcomes
as mentioned above. Additionally, research indicates that childhood access to SNAP is linked to positive
health outcomes as well as school achievement, high school graduation, and adult economic success.
565
Unfortunately, many children in SNAP households are at risk of being cut off from nutrition assistance
because of policies intended to target their parents.
566
,
567
The work requirements in the proposed 2018
House Farm Bill would have put nearly one million parents at risk of losing their household’s nutrition
benefits by 2021, which would worsen household food insecurity.
568
Growing children are especially at
risk of experiencing developmental and emotional issues when there is not enough food in a
household.
569
,
570
Among adolescents, food insecurity is linked to higher rates of anxiety, depression,
substance abuse, and other mental health disorders.
571
,
572
Taking Away Food & Housing Assistance Can De-Stabilize Families
Imposing benefit sanctions on parents who do not meet work requirements could also translate to
stressful, unstable home lives for children, which can have long-term effects on children’s health and
prospects for upward mobility.
573
A study conducted after the Great Recession found that parents
experiencing food insecurity may face increased stress, anxiety, and depression, which may negatively
affect their parenting. Their children often had a harder time focusing and being able to control their
own behavior.
574
Taking away housing assistance from a family with adults that cannot meet a new work
requirement could lead to serious negative consequences for children. Access to decent and stable
housing is strongly linked to several indicators of child and familial well-being, including lower rates of
domestic violence, drug, and alcohol abuse (see Figure 12).
575
Children in families that receive vouchers
are less likely to be removed from their homes and placed in the child welfare system.
576
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Families who face work requirements in public assistance programs may have a higher chance of
becoming involved with the child welfare system. In TANF, this was due to an “emphasis on sanctions
and work requirements, coupled with the lack of adequate child care,” which opened families up to
charges of “inadequate supervision.”
577
For parents or guardians already involved with the child welfare
system, work requirements could be especially damaging for their efforts to keep, maintain custody of,
or reunite with their children. In such cases, parents may have challenges juggling both meeting work
requirements and fulfilling child welfare protocols, such as parenting classes or family counseling,
578
which could delay or decrease the likelihood of reunification.
579
Figure 12. Among families with children, those with increased access to housing choice vouchers face
far lower risk of food insecurity and domestic violence
Experiences for TANF-eligible families participating in 1999-2006 HUD experimental housing voucher
evaluations
INCREASE IN ECONOMIC INSECURITY & HARDSHIP
Work requirements could further entrench families already experiencing poverty and deep poverty, by
leaving them without much needed basic assistance. Under TANF, deep and extreme poverty rates
increased, especially among single mothers and their children.
580
SNAP and housing subsidies decrease
the depth of and number of families in poverty.
581
Without these benefits, many low-income
participants in dire financial circumstances could be driven further into poverty, potentially increasing
deep poverty rates. As medical costs continue to be a key driver of debt
582
for millions of families with
low incomes, people sanctioned off Medicaid may be forced to choose between paying for health
services and paying rent. Including work requirements in housing assistance could increase rental costs
for recipients who are already more likely to be rent-burdened and in poverty, putting them at risk of
homelessness.
583
Due to the burdensome requirements and additional strains work rules place upon low-paid workers
and their families, some may be discouraged from applying or trying to maintain access to such supports
in the first place. Such chilling effects are evident in TANF, where there was a drop in applications from
people who should have been eligible for benefits but did not apply to them, in part because of the
harsh work requirements.
584
Just like with TANF, the likely drop in applications due to these new work
requirements is likely to contribute to a rise in poverty and deep poverty, as otherwise-eligible
individuals and families will be further isolated from the social supports system.
585
HEALTH OUTCOMES LIKELY TO WORSEN
Proposals that take away health coverage from those who do not meet work requirements could result
in worse health outcomes for millions. Over three-quarters (76 percent) of all Medicaid enrollees eligible
for work requirements face multiple challenges to obtaining the employment needed to meet work
requirements.
586
Were Medicaid work requirements implemented nationally, these enrollees would be
in serious danger of losing health coverage.
587
The loss of health coverage could have serious adverse
consequences for millions of current Medicaid participants, including those with disabilities. Among the
11 million individuals who could lose coverage under new Medicaid work requirements were they
applied nationally, 46 percent reported having serious health conditions or being in fair or poor health.
For those in fair or poor health, losing health coverage would significantly elevate the risk of death.
588
Toxic stress that may already exist for some Medicaid participants, due to trauma and the difficulties
associated with experiencing poverty,
589
could worsen due to the threat of losing these fundamental
supports. Under the proposed 2018 House Farm Bill, 2 million households would have no longer be able
to access SNAP benefits.
590
If implemented, lockout periods could result in many Medicaid enrollees receiving infrequent or
disrupted health coverage and services.
591
The lockout periods included in recent work requirement
proposals in Indiana and Kentucky
592
would cut people off health coverage for up to six months if they
fail to meet work requirements or renew their eligibility every year.
593
Once a person has been locked
out, they would lose access to benefits for that time period even if they are later able to fulfill the work
hour requirement or complete their eligibility renewal before the six-month period ends.
594
Such
inconsistent health coverage would be especially harmful for people with behavioral health conditions
who need continuous treatment to be effective.
595
Further, states could see a sizeable loss of health
coverage among recipients just due to the effects of lockout periods. An estimated 25-50 percent of
Medicaid enrollees could lose six-month coverage from lockouts if they fail to meet the eligibility
renewal requirement.
596
Families could also become financially insecure if they lose health coverage and food assistance.
Without health insurance, parents may take on significant debt to cover out of pocket medical expenses.
More than 20 percent of adults had unexpected medical expenses to pay in 2017, and 37 percent had
unpaid debt from medical bills.
597
Families may also forgo medical care altogether if they are unable to
pay out of pocket. In 2017, 39 percent of families with annual incomes below $40,000 went without
medical treatment due to costs.
598
If more states expand work requirements to include Medicaid, the
share of households foregoing needed health care services likely will increase.
FEWER FEDERAL RESOURCES FLOWING INTO LEFT-BEHIND COMMUNITIES
By reducing the flow of well-targeted federal funds to disadvantaged communities, work requirements
in Medicaid,
599
SNAP, and housing assistance could shrink economic development and employment
opportunities overall. According to one estimate, by adding work requirements to Medicaid, the state of
Kentucky's annual loss in federal funds will be akin to losing funding for its entire federal highway
program each year.
600
A reduction in Medicaid funding can have a ripple effect on medical providers as
well. For example, hospitals in rural areas or small towns may be unable to afford to provide critical
treatments at certain locations, forcing patients to drive further in order to access services such as
chemotherapy.
601
As referenced earlier in the paper, the loss of coverage will not only impact the health
of those who are now unable to receive adequate care, but will also lead to increased system-wide
costs.
602
During an economic downturn, work requirements still would apply, and workers who lose their jobs
would be prevented from accessing benefits when they need them most.
603
SNAP responds to
fluctuations in U.S. economic insecurity (see Figure 13). With SNAP, one dollar of benefits results in
approximately $1.74 of economic activity during recessions, and $1.22 in a stronger economy.
604
If work
requirements were imposed broadly, families and communities would have to deal with not only labor
market impacts, but also the loss of access to vital food, medical, and housing assistance, which would
dramatically curtail the ability of both states and the federal government to temper the effects of the
downturn. Even if work requirements were waived at some point during a recession, some damage is
still likely, as people would still lose benefits in the interim. (Area waivers put in place for SNAP work
requirements during the Great Recession are endangered by the Trump administration’s December
2018 proposal to change SNAP work requirement exemptions; see Appendix B for more information.)
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Unworkable & Unwise | 61
SNAP offers large benefits to rural areas and small towns, where it created and bolstered about 567,000
jobs in 2017, including almost 50,000 in agriculture.
605
SNAP also generates revenue for grocery stores
both large and small, making up about 10 percent of all grocery expenditures nationwide,
606
and an even
higher percentage in low-income areas where SNAP benefits are used for a greater portion of sales.
607
Other non-grocery businesses also receive a boost since households that use SNAP then have greater
purchasing power to buy other types of goods too.
608
State government finances benefit as well. A study
in California found that a proposal to expand SNAP eligibility could boost the state’s revenue through
$3.5 million of additional sales tax.
609
Figure 13. SNAP enrollment responds to fluctuations in U.S. economic insecurity
Share of U.S. population near or in poverty & share receiving SNAP benefits, 1977-2017
An Agenda to Increase Employment &
Earnings Would Look Very Different
t is well-established that taking away health coverage, food assistance, and housing assistance from
people who do not meet work requirements is an ill-informed, ineffective, inefficient, and inequitable
approach to increasing employment and improving financial security. Instead of continuing to look to
work rules as a solution, states and other stakeholders should consider the wide range of more
promising tools available to policymakers to bolster employment and improve social assistance
participation among participants who are able to work. This section outlines how a more robust and
effective policy agenda might address individual and systemic barriers to higher employment and
earnings, among other concerns. The section divides the proposed recommendations into three parts:
1) Ensure a foundation for individuals and families, including by ensuring access to and
strengthening programs such as SNAP, Medicaid, housing assistance, and TANF, and raising the
minimum wage;
2) Strengthen family stability, including by modernizing UI and establishing a Jobseeker’s
Allowance (JSA), establishing fair and predictable schedules as well as paid leave, and reforming
the criminal justice system; and
3) Support workers, including by investing in job preparation and creation through proven training
and education, and subsidized and public employment programs; expanding child care
assistance; and boosting the EITC.
Such a policy agenda would draw from a more accurate understanding of Medicaid, SNAP, and housing
assistance; program participants; and the nature of the low-wage labor market, among other
considerations.
Ensure a Foundation for Individuals & Families
Rather than imposing work requirements, ensuring access to work-supporting programs like Medicaid,
SNAP, and housing assistance, strengthening TANF, and raising the minimum wage would all help build a
strong foundation upon which workers and their families can succeed.
ENSURE ACCESS TO WORK SUPPORTS LIKE MEDICAID, SNAP, & HOUSING, INCLUDING
EXPANDING MEDICAID IN ALL STATES
As discussed in the paper, Medicaid, SNAP, and housing assistance programs can enable work and thus
access to these programs should be ensured, rather than limited through a work requirement. All three
programs must be adequately funded and eligibility without restrictions on immigrants. Medicaid should
also be expanded in all states under the ACA to reach more low-income families and support their
work.
610
Positive Uses of Waivers & Other Innovations
Medicaid, SNAP, and housing assistance can help connect people to employment services and jobs
programs. (See the “Support Workers” recommendation for a list of promising models for SNAP and
I
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Unworkable & Unwise | 63
housing assistance programs.) In states, policymakers can leverage Medicaid demonstration waivers to
implement programs that effectively address barriers to employment. For example, Montana has
created a Medicaid initiative that targets barriers to employment and offers intensive outreach to
unemployed Medicaid recipients, including on-the-job training and subsidized employment, operated
through its workforce system.
611
While not formally evaluated at this point, the state reports high
employment rates for participants.
612
States can also offer help with employment under home and
community-based service waivers designed to assist individuals living with disabilities in staying out of
institutional care.
613
Federal policymakers should end the SNAP “ABAWD” time limit, as the policy limits
needed access to food for many low-income individuals and families.
STRENGTHEN TANF
As discussed earlier in the paper, TANF is inaccessible to many families who are eligible for it.
614
Rather
than implementing new work requirements, strengthening TANF would more effectively serve these
populations. Funding levels lost over the past two decades, due to the program’s nominally fixed and
capped block grant structure,
615
,
616
should be restored. TANF’s harsh work requirements should be
replaced with state accountability for poverty reduction and child well-being outcomes, including
through improved earnings and employment.
617
RAISE THE MINIMUM WAGE (INCLUDING FOR TIPPED WORKERS & PEOPLE WITH DISABILITIES)
Raising the minimum wage will make work more feasible, allowing individuals and families to more
easily meet their basic needs in a way that work requirements do not. The minimum wage has eroded
greatly over time (see Figure 14). In 1968, the federal minimum wage was equal to 52.1 percent of the
median wage of all full-time workers; in 2016, that number was 34.9 percent.
618
Currently, the federal
minimum wage is $7.25 per hour, a level it has been at since 2009. Full-time, full-year work for the
minimum wage would yield an annual income of $15,080—less than the poverty line for a single mother
working to support just one child.
619
,
620
One recent proposal to raise the federal minimum wage is the
“Raise the Wage Act of 2019,”
621
which would raise the minimum wage to $15 per hour over several
years.
622
This step would help ensure that more families share in the economic growth of the past half
century.
Figure 14. Value of the federal minimum wage lags behind U.S. economic growth
Real value of the federal minimum wage, actual, and hypothetical, 1968-2017
Strengthen Family Stability
Modernizing Unemployment Insurance and establishing a Jobseeker’s Allowance, establishing fair and
predictable schedules as well as paid leave, and reforming the criminal justice system would greatly
improve the economic stability and labor market outcomes of families.
REFORM UNEMPLOYMENT INSURANCE & ESTABLISH A JOBSEEKER’S ALLOWANCE
Our unemployment insurance system has significant gaps,
623
as only 27 percent of jobless workers
received unemployment insurance in 2016.
624
UI could be strengthened by incentivizing states to link UI
participants with career pathways programs and apprenticeships.
625
States could also expand the eligible
pool of applicants making caregiving a valid reason for a UI application
626
and by banning mandatory
drug testing for UI programs.
627
Even a robust UI program would leave many workers out. A Jobseeker’s
Allowance could reach these workers, including contractors, people exiting prison, young people
entering the job market, and full-time caregivers returning to work. Elsewhere, the Georgetown Center
on Poverty and Inequality, along with the Center for American Progress and National Employment Law
Project, has proposed a JSA that would be parallel and complementary to UI, offering a modest stipend
to jobseekers ineligible for UI for up to 13 weeks for job search and preparation. The JSA would expand
worker access to crucial reemployment services, and we believe “would encourage workforce
participation, support geographic labor mobility, and promote family stability and social cohesion”
628
in
a way that current work requirement proposals fail to do.
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Unworkable & Unwise | 65
ENSURE ACCESS TO QUALITY, DECENT JOBS & FAIR LABOR STANDARDS
The populations mentioned in this paper would greatly benefit from access to quality employment,
rather than facing work requirements that may force them to stay in lower-paid, lower quality jobs. This
section discusses how ensuring predictable scheduling, expanding access to paid family and medical
leave, and expanding worker bargaining power can improve employment and earnings.
Ensuring Predictable Scheduling
As discussed earlier in the paper, significant numbers of lower-wage workers do not have regular hours
of employment. This can make it particularly difficult for individuals with care-taking responsibilities and
limited transportation options to keep jobs or accept employment that assumes irregular hours. One fix
would be to give employees the right to request flexible schedules that fit their responsibilities without
fear of being penalized by the employer. A complementary option would require employers to set
predictable schedules and to have to offer additional “predictability” pay if they change a worker’s
schedule with less than a week’s notice.
629
This would put the costs associated with such flexibility more
squarely on the (more powerful) employer, rather than leaving it on the (less powerful) employee.
Expand Paid Family & Medical Leave
Most low-income workers in the U.S. do not have access to paid family leave and medical leave
(PFML),
630
which contributes to working families losing $20.6 billion in wages annually.
631
The evidence
from state-level PFML programs is promising and demonstrates that ensuring access to PFML is more
helpful for low-income workers than work requirement proposals. Positive outcomes included increases
in work hours
632
and labor force attachment and improved employee performance and health
outcomes.
633
Recommendations to expand access and make it more inclusive include passing a national
law guaranteeing paid leave, ensuring PFML laws include workers at employers of all sizes and part-time
workers, allowing intermittent use of leave, and making sure leave is available without any adverse
employment consequences.
634
Expand Worker Bargaining Power
Expanding workers’ bargaining power can help address many of the barriers to work and difficulties of
the low-wage labor market mentioned earlier.
635
Unions particularly help workers of color,
636
women,
637
and others who face discrimination have better pay and better quality jobs. Unions have been shown to
raise wages for workers whether or not they are in a union,
638
including in professions that are normally
low-paid. They also provide training for workers and can help decrease the pay differential between
workers of different skill levels.
639
Workers in a union are more likely to have employer-provided health
insurance, paid sick and vacation days, and predictable work schedules.
640
Strategies to expand workers’
bargaining power include making it easier to join a union and repealing and stopping the expansion of
state laws that reduce the fees unions can collect, making it harder for them effectively bargain.
641
REFORM THE CRIMINAL JUSTICE SYSTEM
A criminal record leads to barriers to finding education, training, and employment for some populations
who will be affected by new work requirement proposals, especially younger men of color.
642
Mass
incarceration also harms families and can lead to issues such as “family instability, unemployment,
socioeconomic disadvantage, substance use, and mental health problems,” according to the National
Council on Family Relations.
643
More than 70 million Americans have a criminal record of some sort
644
and, by one estimate, employment losses due to criminal records represent about $80 billion in lost in
annual economic output.
645
Recognizing that incarceration as a policy tool has been over-used, a
bipartisan effort has been underway in recent years to reform the criminal justice system. The “First
Step Act,” passed in 2018, granted early release to many individuals convicted of low-level federal
crimes, retroactively reduces disparate sentences for powder versus crack cocaine offenses, and amends
some mandatory minimum sentences to allow judges more discretion.
646
Next steps should build on this
law,
647
and also provide additional funding for re-entry programs, including through Pell Grants,
648
to
give individuals with a record a better chance of finding work, instead of penalizing them through work
requirements. In the long-term, farther-reaching decriminalization and decarceration efforts could lead
to employment and earnings gains for millions of families.
Support Workers
Investing in proven workforce development programs, increasing child care assistance, and expanding
access to the EITC can help individuals with significant barriers to work gain the skills and services they
need to find and keep higher quality jobs, along with rewarding and supporting work in a way that work
requirements do not.
EXPAND PROVEN WORKFORCE DEVELOPMENT FUNDING & REACH
By all accounts, workforce development funding is insufficient and effective programs have not been
brought to scale. Policymakers have many workforce development-focused options for more effectively
people targeted by work requirements.
Boost WIOA & CTE
WIOA is one of the core programs that states use to promote workforce development. It provides
employment, training, and education programs for adults, youth, and dislocated workers, along with
wraparound services.
649
Historically, WIOA has fallen short in helping the most disadvantaged
workers.
650
However, WIOA is already inadequately funded, and funding has been falling for the past 40
years.
651
WIOA funding should be increased, but the workforce system must work for all workers,
particularly those who have multiple barriers to work through the welfare system. Substantially
expanding career and technical education (CTE) is one solution. CTE has been shown to increase
educational attainment rates
652
and to help provide individuals with the skills needed for evolving
industries.
653
Successful programs include sector partnerships, where students receive industry-specific
training to help them meet the needs of local employers.
654
Invest in SNAP E&T
A stronger and easier to administer E&T program would help more SNAP participants find and keep jobs,
especially since evidence suggests that many unemployed childless adults on SNAP have recent work
experience.
655
E&T programs should be adequately funded, and states can use new funding to
specifically focus on groups facing barriers to employment, such as people with low educational
attainment and people with criminal records.
656
As noted earlier, the E&T programs that had the most
success in helping individuals with significant barriers to work combined “individualized assessments,
addressing barriers to employment, and helping participants gain skills and experience[;]”and were
voluntary,
657
which is a stark contrast to work requirements. Such features should be expanded in other
E&T programs.
Build upon Evidence in Housing Programs
Housing assistance can serve as a platform to increase employment and earnings, while improving
health for participants. Two promising approaches, Jobs Plus and the Family Self-Sufficiency Program
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Unworkable & Unwise | 67
(FSS) suggest strategies for policymakers to improve labor market outcomes of housing assistance
participants. Both programs were voluntary,
658
unlike current work requirement proposals.
Jobs Plus Demonstration
Jobs Plus was a demonstration program that operated for 15 years, beginning in 1998, in six public
housing developments as part of a rigorous randomized controlled trial. Jobs Plus had three elements –
on-site job centers, rent rules that provided more financial incentive to work, and community support
for work through neighbor-to-neighbor conversations.
659
The results of the Jobs Plus demonstration
were striking. Residents earned an average of 14 percent more per year than those at the control sites
without Jobs Plus. Even more importantly, the impact continued after the program concluded, with
residents at Jobs Plus sites earning 19 percent more per year.
660
Broader implementation of Jobs Plus
could increase labor force participation among public housing residents.
Family Self-Sufficiency Program (FSS)
FSS is a promising housing program administered by PHAs for families receiving public housing or
Section 8 Housing Choice Voucher assistance. Primarily funded by the federal government, FSS
combines case management support for employment and other goals, with an escrow savings account
for families who pay higher rents as their incomes rise.
661
After five years, participating families can
withdraw funds from their escrow accounts for any purpose.
662
Research on FSS indicates that the
program supports positive employment and earnings outcomes
663
for participants, along with greater
economic security through asset building.
664
Currently, fewer than five percent of qualifying families in
public housing and Section 8 Housing Choice Voucher programs participate in FSS.
665
In partnership with
local PHAs, the U.S. Department of Housing and Urban Development (HUD) can support increased
awareness of the FSS program among eligible families.
666
Additionally federal agencies can foster
collaboration between PHAs and TANF agencies to increase FSS participation among TANF families
subject to work requirements, which would increase the amount of services and resources for work-
related activities available to them.
667
DEVELOP SUBSIDIZED & PUBLIC EMPLOYMENT PROGRAMS TO ADDRESS BARRIERS TO
EMPLOYMENT, INCLUDING PLACE-BASED DISPARITIES
Unlike work requirements, a proven yet underutilized strategy for increasing employment and reducing
poverty is subsidized employment programs.
668
Such programs specifically target individuals with
significant barriers to employment, including people in areas of concentrated joblessness, and provide
participants with wage-paying jobs, training, and wraparound services, while offsetting employers’
costs.
669
As mentioned earlier, such programs have seen positive impacts on earnings
670
and
employment,
671
even after the program duration, and have specifically helped people returning from
prison and reduced recidivism rates.
672
Creating a national subsidized employment program with
dedicated and flexible funding streams could lead to further-reaching gains for the well-being of
participating workers and their families, employers, and communities.
673
This program could be
complemented by a well-designed and implemented public employment option.
674
EXPAND CHILD CARE ASSISTANCE
For parents and guardians, safe and reliable child care is necessary to be able to work, particularly if they
work in industries with irregular schedules and hours. Child care is expensive and can take up much of a
family’s income, especially for those working in low-wage jobs.
675
Federal funding for the main program
that provides child care assistance, the Child Care and Development Block Grant (CCDBG), has largely
stagnated (though a large, one-time increase was passed in 2018
676
) and has not kept up with the cost of
child care, resulting in a reduction in purchasing power in real terms.
677
While some child care funding
comes from other sources such as TANF
678
and Social Services Block Grant (SSBG),
679
these funds are also
under threat.
680
As it is, the vast majority of low-income parents eligible for child care subsidies do not
receive them.
681
Funding for child care needs a large investment through the CCDBG and other funding
sources in order to reach more families. Vouchers that help families in need of care during
nontraditional hours also should be established, along with subsidies specifically for the creation of new
jobs in child care, to further increase access to quality care.
682
EXPAND THE EARNED INCOME TAX CREDIT (EITC)
The EITC supplements low-wage work
683
by providing an annual lump sum payment after individuals and
families file their federal income tax returns.
684
Research has found that the current structure of the
EITC, which overwhelmingly benefits families raising children,
685
raises single parents’ employment.
686
The EITC has been expanded on numerous occasions since it was created in the 1970s and should be
expanded again to reach more low-income individuals.
687
One such proposal is known as “Paycheck
Plus,” which has been tested thus far in New York City and Atlanta.
688
The program provided low-wage
workers without dependent children a bonus of up to $2,000 at tax time.
689
An evaluation by MDRC
found an increase in after-bonus earnings, a reduction in severe poverty, and relatively higher
employment rates, especially among women and lower-income participants.
690
This suggests that the
populations described in this paper would be better served by the implementation of a Paycheck Plus-
style expansion of the EITC rather than through an expansion of work requirements.
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Unworkable & Unwise | 69
Conclusion
edicaid, SNAP, and housing assistance help ensure a foundation for tens of millions of families
in the U.S. Taking away Medicaid, SNAP, and housing assistance if people do not meet and
document meeting work requirements misunderstands the contributions of and obstacles
faced by working people in the U.S., and fails to address the underlying reasons for relying on such
programs in the first place.
691
By undermining the necessary and productive purposes of SNAP, Medicaid
and housing assistance, work requirements will cause real harm, especially to people who are already
among the most disadvantaged.
692
Imposing work requirements for health care, food, or housing
destabilizes families. Thus, the push for “work requirements” is likely to make life worse for many
current and aspiring workers and their families, whether already employed, in training or education, or
in the midst of a job search. In fact, current proposals to take benefits away from people appear more
likely to penalize those already working than to increase participants’ employment or earnings.
693
For
these and other reasons, work requirements are ill-informed, ineffective, inefficient, and inequitable.
Policymakers would be wise to reconsider the value of work requirements and the assumptions
underlying them. Work requirements come with substantial downside and little upside. These harsh
proposals reflect a lack of understanding for the realities of low-wage work in America, as well as the
range of barriers to higher employment and earnings. Struggling families need a reality-based agenda to
improve their health and financial well-being. Research and evidence point to a different path forward
than work requirements that take away essential food, housing, and health care program benefits.
Programs like SNAP, Medicaid, and housing assistance help millions of individuals and families meet
basic needs and serve as highly effective anti-poverty programs.
694
,
695
,
696
In contrast, the anti-poverty
effects of mandatory work requirements under other programs are mixed at best and
counterproductive for many subject to these harsh rules. Medicaid, SNAP, and housing assistance
certainly can promote and support work and economic opportunity more effectively, including by
connecting participants with voluntary job preparation and placement programs that address the
barriers they face. A host of other approaches, such as increasing the availability and affordability of
child care or expanding the EITC, would do far more to promote work than the cuts being implemented
and proposed today.
M
Appendices
Appendix A. Medicaid
SUMMARY OF MEDICAID WAIVERS PERMITTING STATE WORK REQUIREMENTS
Medicaid is a federal- state partnership that provides health coverage to tens of millions of people,
including eligible low-income adults, children, pregnant women, elderly adults, and people with
disabilities. Following the passage of the ACA in 2014, the federal government authorized states to
expand Medicaid eligibility to individuals under age 65 in families with incomes below 133 percent of
the federal poverty level.
697
,
698
To date, 37 states, including the District of Columbia, have expanded
Medicaid eligibility in response.
699
In 2017, House Republicans sought first to establish a work
requirement in Medicaid as part of their legislation to repeal the ACA.
700
After this effort failed in the
Senate, proponents of work requirements turned to pursuing work requirements through administrative
actions by the Trump Administration.
Under the Trump Administration, the U.S. Department of Health and Human Services (HHS) has taken an
unprecedented step, inviting states to apply for Section 1115 waivers under the Social Security Act to
introduce work requirements in Medicaid for the first time in the half-century history of Medicaid.
701
A
January 2018 letter from CMS to state Medicaid directors supported the imposition of work
requirements, detailing policy guidelines for what CMS would be willing to approve.
702
In the year
following the letter, seven
703
states received approval to implement work requirement programs and
nine states
704
have proposals pending.
705
,
706
Who Is Affected by Medicaid Work Requirements
The work requirements currently approved in seven states are similar but not identical. They apply
largely to the “expansion” population made eligible under the ACA, made up of low-income, adults not
raising children, and they mandate meeting and documenting a work requirement of 80 hours per
month (100 hours per month in New Hampshire) for most adults in the expansion population.
707
Another point of variance is exemptions. While CMS’ policy guidance states that work requirement
demonstrations would target “non-elderly, non-pregnant adult Medicaid beneficiaries who are eligible
for Medicaid on a basis other than disability,” CMS does not explicitly require states to exempt certain
at-risk populations from work requirements. Rather, CMS suggests that states “may wish to consider”
exempting caregivers, individuals with health-related barriers to work, survivors of domestic violence,
and other at-risk populations from work requirements, similar to policies in SNAP and TANF.
708
The
broad parameters of CMS’ guidance leave states with ample autonomy and limited accountability in
how they design work requirements. For example, Kentucky, Maine, and New Hampshire only exempt
those 65 and older while Indiana (60), Michigan (63), Wisconsin (50), and Arkansas (50) set lower
ages.
709
A subject of discussion in 2018 was the degree to which the non-expansion population within Medicaid
can have these requirements applied to them. CMS Administrator Seema Verma has signaled concerns
about some waivers that reach into the traditional Medicaid population. In an April 2018 legal brief filed
as part of pending litigation over the Kentucky waiver, CMS stated that these requirements were
primarily for adults in expansion states.
710
However, CMS has approved waivers for Wisconsin and
Maine, two states that would apply work requirements to traditional, non-expansion enrollees.
711
This
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Unworkable & Unwise | 71
raises questions about whether waiver applications from non-expansion states like Mississippi and
Kansas will move forward.
Challenges to the Legality of Medicaid Work Requirements
Under the Social Security Act, the statutory purpose of Medicaid is, “to furnish medical assistance,” to
people with low incomes.
712
,
713
Following CMS’ first approval of Medicaid work requirements in
Kentucky, the question of whether these requirements are permissible in Medicaid under current law
have become the subject of legal and public debate.
A number of federal and state lawsuits have been filed challenging the legality of work requirements
under the Medicaid statute. One lawsuit filed against HHS in the weeks following Kentucky’s waiver
approval argued, among other things, that the waiver amounted to “effectively rewriting the [Medicaid]
statute,” which is impermissible without Congressional action.
714
,
715
In response, Kentucky Gov. Matt
Bevin filed a countersuit, and threatened to end Medicaid expansion in Kentucky if work requirements
were not implemented.
716
A federal judge later blocked CMS’ Kentucky waiver approval on June 29,
2018 ruling that HHS had acted in an “arbitrary and capricious” manner in approving it, failing to
adequately consider whether the waiver proposal actually met Medicaid’s objectives.
717
,
718
HHS then re-
opened the comment period on the waiver, presumably to gather additional input that would address
the judge’s objection. CMS ultimately re-approved Kentucky’s waiver on November 21, 2018, allowing
the state to begin implementing work requirements as early as April 2019.
719
Kentucky’s waiver was
challenged again on January 15, 2019, when over a dozen Medicaid beneficiaries filed another lawsuit
against the federal government for its re-approval the state’s waiver.
720
As of January 31, 2019, a final
ruling has not been made.
While the Kentucky waiver was on hold due to the litigation, Arkansas began implementing work
requirements in June 2018. Beginning on June 1, non-exempt enrollees in the expansion population ages
30 to 49 were required to document 80 hours of work-related activities per month via an online portal
to maintain their health coverage.
721
By December 2018, an estimated 18,000 people had lost health
coverage due to the new policy.
722
Rattled by the dramatic drop in enrollment, the Medicaid and CHIP
Access Payment Commission released a letter urging the Trump Administration to halt implementation
of Arkansas’ work requirements program, citing the massive loss of coverage from people failing to
comply.
723
The commission requested a pause in revoking health coverage to allow for more outreach
and communication about the state’s new policy.
724
On August 14, 2018, three Medicaid enrollees who
lost coverage filed a federal lawsuit against HHS on the basis that Arkansas’ work requirements program
was unconstitutional. The case is currently proceeding and a final verdict has not been reached.
725
Arkansas later announced in December 2018 that Medicaid enrollees would now be able to report hours
by phone (rather than just online) in large part due to the outrage over significant coverage loss among
enrollees subject to work requirements.
726
Medicaid Work Requirements May Not Be Evaluated as Required by Law
As with any type of state-led demonstration, regular and timely evaluations are imperative for ensuring
the effectiveness and efficiency of the programs. They suggest and guide improvements and serve as
critical oversight tools for the federal government. While CMS guidance suggests that states "evaluate
health and other outcomes of individuals that have been enrolled in and subject to the provisions of the
demonstration," in practice CMS has not made this a priority.
727
In 2018, CMS allowed the Arkansas
work requirement waiver to begin before an evaluation plan was agreed upon with the state.
728
Furthermore, in the past (prior to Medicaid work requirement proposals), CMS has not followed through
on its commitment to produce independent public evaluations of Medicaid demonstrations. According
to a U.S. Government Accountability Office (GAO) report on previous Medicaid demonstration
evaluations, "the federal government did not require complete and timely evaluations from states," and
"the federal government was not making its evaluation results public—missing opportunities to inform
federal and state Medicaid policy discussions."
729
These findings pose doubts about the likelihood of
future Medicaid demonstration evaluations being conducted and/or produced under the Section 1115
authority. Current arrangements between CMS and states also raise doubts about the federal
government’s prioritization of evaluation.
Working Paper
Unworkable & Unwise | 73
SUMMARY OF APPROVED MEDICAID WORK REQUIREMENT POLICIES
State
Background
Who is Subject to
Work
Requirements?
State-set Exemptions
What are the
Requirements?
What are the
Sanctions?
Impacts to date (as
of Dec. 2018)
Kentucky
KY was the first state to
receive federal (CMS)
approval to institute
Medicaid work
requirements (Jan. 2018).
Medicaid expansion
730
enrollees without
disabilities between the
ages of 19 and 64.
731
Full-time students; former foster
care youth; pregnant women;
people with serious medical
conditions; primary caregivers of
adults with disabilities or
dependent children; domestic
violence survivors; elderly adults
(65 and above); and people with
disabilities (based on SSI
qualification).
732,733
Former foster youth and people
who are “medically frail” must
pay monthly premiums to get
access to vision and dental
services.
734
Perform 80 hours of work-
related activities per month
(or prove exemption).
Approved activities include:
working, volunteering, job
searching, educational or
vocational training, and
substance abuse treatment
among other things.
735
Failure to prove exemption
or meet work requirements
results in a 6-month lockout
period from accessing
Medicaid.
736
Experts estimate that work
requirements would double
the number of adults who
dis-enroll from Medicaid in
two years.
737
Additionally, up to 70,000
KY adults could lose
coverage permanently due
to work requirements.
738
Arkansas
On June 1 2018, AR became
the first state to implement
work requirements in
Medicaid.
739
Mainly adults aged 29-50
who are non-elderly and
without disabilities. By
2019, the target population
will include adults aged 19-
29, adding 45,000 more
people subject to work
requirements.
740, 741
Full-time students; people
receiving TEA cash assistance;
742
people deemed medically frail,
disabled, or incapacitated; people
with physical or mentally health
conditions; caregivers for
incapacitated persons; parents w/
children under 17; people
receiving unemployment benefits;
people enrolled in alcohol or
substance abuse program;
pregnant women; and people
exempt from SNAP work
requirements.
743
Perform 80 hours of work-
related activities each
month (or prove
exemption).
Qualifying activities include:
unsubsidized employment,
enrollment in school, job
training, vocational school,
or other education
programs; community
service, job searching (up to
39 hours/month);
enrollment in health
education classes (up to 20
hours/month);
744
and any
activity that satisfies SNAP
work requirements.
745
Those subject to work
requirements are required
to document their hours or
Work-eligible adults who do
not meet work
requirements will lose their
Medicaid benefits after 3
months.
747
Enrollees will
also be locked out of
coverage until the next
enrollment cycle.
748
In the first month of
implementation (June
2018), about 25,815
Medicaid adults were
subject to work
requirements.
749
About 18,000 AR enrollees
(22%) of those subject to
work requirements have
lost Medicaid coverage.
750
Conditioning Access to Programs that Ensure a Basic Foundation for Families on Work Requirements | 74
exemption via an online
portal.
746
Indiana
In 2015 under then-Gov.
Mike Pence, IN expanded
access to Medicaid under
the ACA. However, the state
included a provision
requiring Medicaid
expansion enrollees to
make monthly payments
ranging from $1-27 to keep
their benefits.
751
The
Medicaid expansion
program was set to expire in
January 2018, but IN
applied for a waiver to
extend the program and
include work requirements.
CMS approved IN’s waiver
in February 2018, and the
state is set to begin
implementing work
requirements in 2019
through 2020.
752
“Non-elderly, non-disabled”
adults aged 19-59.
753
The
target population for work
requirements are those
enrolled in HIP Plus, IN’s
Medicaid expansion
program.
754
Full- and part-time students;
pregnant women; primary
caregiver of children under age
seven or a person with
disabilities; people deemed
medically frail or incapacitated;
people who are homeless, people
with a serious illness; people
incarcerated in the last 6 months;
people exempt from or meeting
TANF work requirements; and
people enrolled in Medicaid
employer premium assistance
program.
755
Perform 20 hours of work-
related activities per month
(or prove exemption). The
required work hours will
increase to 80 hours per
month by 2020.
756
Qualifying activities include:
subsidized and unsubsidized
employment; state-run
employment initiatives;
757
job skills or vocational
training; homeschool, high
school, college and ESL
758
education; job searching;
volunteering; caregiving
activities; enrollment in
Indiana’s work-referral
program;
759
enrollment in
tribal nation workforce
programs; enrollment in a
substance abuse treatment
program; and meeting SNAP
work requirements.
760
Enrollees must meet work
requirements for eight
months out of the year.
761
Additionally, Medicaid
expansion enrollees are
required to make monthly
payments into health
savings accounts within a
60-day grace period and
must re-determine eligibility
for Medicaid annually.
762
Work-eligible enrollees who
do not document hours or
exemption from work
requirements by the end of
a 12-month period will lose
benefits beginning the first
day of the following year.
Enrollees can reactivate
their eligibility to receive
benefits after they complete
one month of work-related
activities.
763
Additionally enrollees who
do not submit their
Medicaid redetermination
paperwork within a 90-day
grace period will be locked
out of enrolling for three
months.
764
The new waiver will also
include lockout periods for
enrollees who fail to make
their monthly payments in
the health savings account
within a 60-day timeline.
Enrollees with incomes
above 100% FPL will lose all
of their benefits for a six-
month lockout period.
765
Those with incomes at or
below the federal poverty
line will lose some
benefits.
766
While the new policy will
not take effect until 2019,
the changes are projected
to cut Medicaid enrollment
by 1% in the first year.
767
Under the previous
amendment, 46,000
enrollees were locked out of
coverage for failing to make
initial payments, and since
2015, over 91,000 enrollees
in IN lost health coverage
for not meeting the
eligibility redetermination
requirement.
768
The work
requirements rule is
predicted to affect about
85,000 Medicaid enrollees
beginning in 2019.
769
New
Hampshire
Under Gov. Chris Sununu,
NH sought to institute work
requirements on adults who
gained health coverage
“Non-elderly, non-disabled”
adults aged 19-64. Adults
with children above age 6
are also subject to work
requirements.
776
People who are hospitalized,
seriously ill, or incapacitated;
caretakers for people who are
seriously ill, incapacitated, or
hospitalized; people participating
in drug court; parents with a child
Perform 100 hours of work-
related activities per month
(or prove exemption).
Qualifying activities include:
subsidized or unsubsidized
Enrollees who do not meet
work requirements or
exemptions will have one
month to make up their
unreported hours, or prove
a ”good cause” exemption
On December 20, 2018, the
Joint Legislative Committee
on Administrative Rules, a
bipartisan panel of state
legislators unanimously
objected to the new work
Working Paper
Unworkable & Unwise | 75
under Medicaid expansion
in 2014.
770
Prior to 2018, NH had
implemented a section 1115
demonstration waiver that
included a voluntary work
referral program, but in
2017 the state applied for
an amendment that would
institute work
requirements.
771
CMS first
approved the state’s waiver
but only until December
2018.
772
On November 30,
2018, CMS extended the
waiver to implement
Medicaid work
requirements until
December 2023.
773, 774
Implementation will begin
January 2019.
775
Enrollees with incomes
above 100% FPL will be
required to make
copayments for Medicaid
coverage.
777
under age 6 (one parent is
exempt in the case of two-parent
homes); parents of a child with a
disability (one parent is exempt in
the case of two-parent homes);
pregnant women; people with a
disability (as defined under
American Disabilities Act); people
exempt from SNAP or TANF work
requirements; people enrolled in
Nh’s voluntary Health Insurance
Program (HIPP); and elderly
adults (above age 64).
778
employment; job skills or
vocational training; high
school or college
enrollment; enrollment in
substance abuse treatment
program; volunteering;
caregiving for a person with
physical or mental health
conditions; and fulfilling
SNAP or TANF work
requirements.
779
from making up those
hours. Enrollees who do not
meet the 1-month deadline
will then lose their benefits,
and must re-apply to get
back coverage.
780
requirements policy, due to
a number of disagreements
with the policy. However,
the state health agency
plans to continue
implementation of work
requirements without the
panel’s approval beginning
in 2019.
781
Maine
Under Gov. Paul LePage, ME
first submitted a request to
institute work requirements
in August 2017, and on
December 21, 2018 CMS
approved the state’s waiver
to implement work
requirements.
782
As ME did
not expand Medicaid
coverage under the ACA,
the work requirements
waiver approved by CMS
would apply to the
traditional Medicaid
population or those making
below $12,000 annually.
783
“Non-elderly, non-disabled”
adults ages 19-64.
784
Elderly (age 65+) enrollees;
people with disabilities (recipients
of disability benefits); pregnant
women; parents with children
under age 6; people physically or
mentally unable to work; people
housed in an institutional facility;
and caregivers of incapacitated
adults.
785
786
Perform 80 hours of work-
related activities per month
to maintain coverage.
Additionally, enrollees with
incomes above 50% FPL will
have to pay monthly
premiums of up to $40.
787
788
Qualifying activities include:
unsubsidized employment
or state-sponsored workfare
program, enrollment in
school (at least part time),
job searching; job training
and education; community
service; receiving
unemployment benefits;
and meeting SNAP or TANF
work requirements.
789
Enrollees who do not meet
the work requirements will
only be able to access
health coverage for 3
months out of every three
years, until they come into
compliance with the
requirements.
790
Additionally, enrollees who
fail to pay their monthly
premiums would lose
coverage after a 60-day
grace period, until they
make of their missed
payments.
791
While the work
requirements
demonstration has yet to be
implemented, advocacy
group Maine Equal Justice
Partners estimates that up
to 50,000 people could be
affected by the monthly
premiums.
792
The state also estimates
that while enrollment
numbers will decline,
Medicaid costs will likely
increase over time due to
declines in enrollment
among low-cost
beneficiaries.
793
Conditioning Access to Programs that Ensure a Basic Foundation for Families on Work Requirements | 76
Michigan
MI expanded Medicaid coverage to
reach more low-income adults
under the ACA. However, in
September 2018 the state
submitted a request for the work
requirements demonstration
through the section 1115 waiver.
On December 21, 2018, CMS
approved MI’s waiver to
implement work requirements.
794
“Non-elderly, non-disabled”
adults ages 19-62.
795
Seniors (age 63+); pregnant
women; parents of children
under age 6; people
receiving disability benefits;
full time students who are
dependents or have a
parent/guardian on
Medicaid; caregivers of
people with disabilities or
incapacitated individuals;
people deemed medically
unable to work; people
incarcerated in the last 6
months; former foster
youth under age 21; and
people meeting or exempt
from TANF or SNAP work
requirements.
796
Perform 80 hours of work-
related activities per month
to maintain coverage.
797
Non-exempt enrollees will
be required to either meet
or prove exemption from
the requirements on a
monthly basis.
798
Enrollees who do not meet
work requirements will only
have health coverage for 3
months in year, after which
they will lose coverage until
they come into
compliance.
799
MI’s work requirement
policy could affect 540,000-
700,000 people.
800,801
Work requirements could
increase administration
costs by $20-30 million each
year for the Michigan Dept.
of Health.
802
Up to 10% of Medicaid
recipients could dis-enroll or
lose coverage due to work
requirements.
803
Wisconsin
WI first applied for a waiver
in 2017, and on October 30,
2018 HHS approved the
state’s waiver to implement
work requirements.
Although WI did not expand
Medicaid under the ACA,
804
the state did expand
eligibility through a 2014
demonstration waiver to
childless adults at or below
100% FPL.
“Non-elderly, non-
disabled,” childless adults
ages 19-49.
805
Elderly enrollees (age 50+),
pregnant women, people
receiving disability benefits;
caregivers; adults deemed
medically unable to work; people
experiencing homelessness;
students; people undergoing
substance abuse treatment; and
adults exempt from SNAP work
requirements.
806
Perform 80 hours a month
of work-related activities to
maintain coverage.
807
Enrollees at or below 100%
FPL will be required to pay
monthly premiums of up to
$8.
808
Enrollees will also pay
premiums for emergency
room visits deemed “non-
emergency.”
809
Work-related activities
include employment;
community service; and
participation in a state-
approved employment and
training program.
810
Those who fail to meet the
work requirements will lose
Medicaid benefits after 48
months. Once dropped from
Medicaid, enrollees will be
locked out for 6 months
before they can reapply.
811
Enrollees who do not make
premium payments will also
be locked out of enrollment
for 6 months, however they
can re-enroll during the 6-
month period if they pay
their late payments.
812
The Wisconsin Dept. of
Health Services estimates
that 148,156 adults will be
affected by the new
policy.
813
According to state
estimates, Medicaid
enrollment could decrease
by 5,000 due to the new
policy and 4,262 people
could be dis-enrolled after
the 48-month limit.
814
Arizona
On January 18, 2019, CMS
approved AZ’s waiver to
implement work
requirements.
815
The work requirements
policy targets Medicaid
expansion enrollees who
“Non-elderly, non-disabled”
adults ages 19-49.
817
Elderly enrollees (50+); people
with disabilities or who are
medically frail; people with acute
physical and mental health
conditions; people enrolled in
substance abuse treatment;
pregnant women and women
who given birth in the last 90
days; full time students; former
Perform 80 hours a month
of work-related activities to
maintain coverage.
819
Qualifying activities include
subsidized or unsubsidized
employment; job or life
skills training; part-time
schooling; health education;
Those who fail to meet the
requirements will have their
benefits suspended after a
3-month grace period.
821
Enrollees whose benefits
are suspended will be
locked out of coverage for 2
months, after which they
AZ is set to begin
implementation of work
requirements in January
2020.
According to state
estimates, the new work
requirements policy will
Working Paper
Unworkable & Unwise | 77
gained eligibility in 2014
under the ACA.
816
foster youth under age 26;
domestic violence survivors;
people experiencing
homelessness; caregivers;
caretakers with a child under 18;
recipients of SNAP, Cash
Assistance, or UI benefits; and
AIAN tribe members.
818
job searching; and
community service.
820
can re-activate eligibility if
they meet eligibility
criteria.
822
affect 120,000 people in
AZ.
823
Appendix B. SNAP
In 2018, the SNAP
824
reached over 40 million people, or about 20 million households in the U.S.
825
The
majority of SNAP recipients (two-thirds) are children, elderly, or people with disabilities.
826
Eligibility for
the benefit, which averages $125 per person each month,
827
depends on a household’s income and in
some cases assets.
EXISTING SNAP WORK REQUIREMENTS
Under current SNAP policy, adults without disabilities
828
between the ages of 18-59 are required to
either work part-time or accept a job if offered one to maintain program participation.
829
,
830
Within the
population of SNAP recipients subject to general work requirements, another group current policy
(misleadingly) calls “Able-Bodied Adults without Dependents,” or “ABAWDs,” must meet a stricter set of
requirements.
According to these requirements, participants aged 18-49 must perform 80 hours of work-related
activities per month in order to keep SNAP benefits. If they cannot meet these requirements, access to
SNAP is time-limited to just three months for every three years.
831
These participants can fulfill the work
requirement if they are employed; enrolled in education or training programs; participated in the SNAP
Employment and Training program (SNAP E&T); or participate in a workfare program
832
for the 80-hour
monthly minimum.
833
They must also refrain from quitting work or reducing their work hours by more
than 30 hours a month to keep their benefits.
834
If a person who falls under ABAWD criteria fails to meet
these set of requirements, they would lose SNAP benefits for one month in the first instance, three
months for the second instance, and six months for the third.
835
Certain adult SNAP recipients are exempt from the time limits. These include people deemed unable to
work due to mental or physical health conditions; pregnant women; adults caring for a child or an
incapacitated person (though this exemption may be applied disparately, as there is a lack of clarity in
U.S. Department of Agriculture (USDA) guidelines regarding who might qualify under this category);
836
and people who are exempt from the general SNAP work requirements.
837
Additionally, prior to the
proposed 2018 House Farm Bill, a state could provide time limit exemptions for up to 15 percent of its
SNAP caseload that would lose benefits because of the ABAWD time limit.
838
The exemption would
enable participants subject to time limits to use SNAP for one additional month past the time limit.
839
States also can apply for yearlong waivers to exempt participants from the work requirement time limit
if they are in areas with high unemployment (10 percent or above) or during an economic downturn.
840
However, the general work requirements would still be in effect.
841
As of this writing, five states, the
District of Columbia, and Guam all have statewide ABAWD time limit waivers in effect. Twenty-nine
states have partial waivers that exempt participants from the time limits only in certain areas of the
state, and 17 states do not have waivers for people subject to a time limit.
842
The ABAWD time-limited population represents a small fraction of SNAP recipients; in 2016, 8.8 percent
of all SNAP participants were deemed time-limited.
843
Among the time-limited population, 26 percent
were working largely in low-paying jobs,
844
and on average, participants who were time-limited live in
deep poverty, at 33 percent of the federal poverty level.
845
2018 HOUSE REPUBLICAN FARM BILL SNAP WORK REQUIREMENT PROPOSAL
The proposed 2018 House Farm Bill included provisions that built upon and expanded existing work
requirement policies in SNAP. More specifically, the legislation would have:
Working Paper
Unworkable & Unwise | 79
• Expanded the time-limited population from adults aged 18-49 to 18-59;
• Required participants who were time-limited to demonstrate at least 20 hours of
employment per week or participation in a qualifying job training program (by 2021, the
required hours of employment would increase to 25 hours per week);
• Exempted people with a qualifying disability, people over age 60, pregnant adults, and
adults caring for children under the age of six or a person with substantial health limitations
from work requirements;
846
• Blocked individuals’ SNAP benefits for 12 months if they fail to meet the requirement in a
single month;
• Cut off SNAP benefits for three years if an individual fails to meet the requirement a second
time;
847
and
• Increased federal funding to states for SNAP Employment and Training (E&T) programs,
from $90 million to $1 billion by 2021.
848
The proposed 2018 House Farm Bill also included a number of amendments that would make it more
difficult for states to utilize waivers on time limits and exemptions for time-limited participants facing
barriers to meeting work requirements. Currently, time-limited participants are allowed SNAP benefits
for only three months out of every three years if they do not meet work requirements.
849
However, for
certain time-limited populations in areas of high unemployment, states have the option to waive the
three-month time limit on SNAP.
850
Under the proposed 2018 House Farm Bill, states would face stricter
criteria in applying for time limit waivers,
851
which could result in an estimated additional 600,000
people losing their SNAP benefits in 2021 when the bill would go into effect.
852
The bill also includes an
amendment to narrow the time limit exemption, which gives states flexibility to exempt a share of their
time-limited population from time limits for one month.
853
The proposed amendment would restrict the
time limit exemption from 15 percent of a state’s caseload to 12 percent.
854
Another amendment would
require any E&T funds not spent within one year to be returned to the federal government,
855
which
could effectively reduce job training funds by $350 million over ten years.
856
Two additional
amendments included in the bill consist of proposals to privatize the administration of SNAP
programs,
857
and a lifetime ban on receiving SNAP benefits for individuals convicted on certain violent
crimes.
858
The Farm Bill was initially voted down in the House on May 18, 2018
859
but Republican leaders rounded
up additional support for a second floor vote on June 21, 2018 and were able to pass the bill.
860
However, the Senate passed its own version of the Farm Bill on June 28, 2018 which did not include
changes or expansions to SNAP work requirements. Negotiations between the House and Senate bills
were decided in the conference committee which convened in early September 2018.
861
After two
months of negotiations, the conference committee reached a deal on the Farm Bill which did not include
any major changes to SNAP work requirements, except the amendment to restrict the time limit
exemption from 15 percent of a state’s enrollment to 12 percent.
862
,
863
,
864
The final version of the Farm
Bill was voted on and passed both houses on December 12, 2018.
865
THE TRUMP ADMINISTRATION’S PROPOSED RULE ON TIME LIMITS
On December 20, 2018, the Trump Administration released a proposed rule
866
to limit the criteria under
which states can apply for time limit waivers for SNAP participants who are unable to document
sufficient hours of work each month.
867
Currently, states are able to apply for waivers to the three-
month time limit on SNAP for participants who face time limits in cases where the unemployment rate is
20 percent above the national unemployment rate.
868
The new rule would restrict applications to states
where the unemployment rate is above seven percent, almost two times as much as the current
national rate.
869
The proposed rule also would require states to re-apply for waivers every year, rather
than every two years based on current rules.
870
Additionally, the rule would prohibit states from carrying
over unused exemptions into the following year from the 15 percent caseload exemptions allotted
under current SNAP policy.
871
Under the Trump Administration’s proposal, 755,000 people could be
impacted by the restrictions on waivers.
872
The proposal was released shortly after Congress passed the
2018 Farm Bill which did not include any changes to SNAP work requirements.
Working Paper
Unworkable & Unwise | 81
Appendix C. Housing
Federal housing aid for low-income populations comprises a number of direct and indirect rental
assistance programs. This report discusses proposed work requirements for two types of direct housing
assistance: public housing and Housing Choice Vouchers (HCVs). In public housing, residents pay an
income-based rent for an apartment in a building owned by a local housing agency. For those who
receive voucher-based rental assistance, they pay income-based rent for an apartment in a privately-
owned building with the federal government paying the difference to the landlord.
Federal housing assistance is capped, and reaches just a fraction (one-quarter) of those eligible.
873
Waiting lists are long, and in some places applicants may remain on the list for years before receiving
assistance.
874
Demand is so high that a majority of housing agencies have closed their waiting lists.
875
By
one estimate, there are nearly 3 million families currently on a waiting list for HCVs, and approximately
1.6 million families waiting for public housing units in the U.S.
876
The same estimate found that if all
waiting lists were re-opened, the lists would swell to 9 million families and 2 million families waiting for
vouchers and housing units, respectively.
877
Under current law, unemployed adults in public housing units already have a requirement to participate
for eight hours a month in community service or work-related activities.
878
This can be satisfied in a
variety of ways, such as community service, training, or simply volunteering. There are exemptions for
those who are elderly, disabled, or already meeting the participation requirements of TANF. The Trump
Administration has indicated an interest in intensifying and expanding work requirements to a broader
swath of housing assistance program participants.
House Republicans too have indicated an interest in work-related mandates. The 2016 poverty policy
plan issued by House Republicans proposed to “require housing to align with TANF benefits.”
879
This was
further detailed to make clear the intent:
“Those [who are] work-capable recipients should be expected to work or prepare for work by
meeting with TANF case workers who collaborate with them to develop plans to obtain work
and assist in making arrangements to prepare for work, such as child care, transportation, work
clothes, and other necessities to transition to regular employment. Additionally, local
jurisdictions that administer housing benefits should have the same program guidance that
states mandate for TANF beneficiaries, such as the ability to institute work requirements,
educational training, and time limits beyond which benefits are discontinued to encourage non-
working work capable recipients to move toward jobs, careers, and economic independence.”
880
TRUMP ADMINISTRATION FY2018 BUDGET PROPOSAL
In May 2017 the Trump administration released its budget for FY2018 that included dramatic cuts and
changes to programs administered by HUD. The administration stated in the budget that it plans to
implement work requirements and other program changes in 2019 to achieve its aim of creating “a path
for work-able families to move toward self-sufficiency.”
881
The budget also included a 13.2 percent cut
to overall HUD funding, and elimination of a number of programs it claimed have been ineffective at
address community development and revitalization challenges.
882
These programs include the
Community Development Block Grant, Choice Neighborhoods Initiative, HOME Investment Partnerships
Program, the Self-Help Homeownership Program and the Indian Community Development Block
Grant.
883
In addition to the funding cuts, the budget also enabled HUD to raise the share of rent housing
assistance recipients pay from 30 percent of adjusted family income to 35 percent.
884
For the lowest-
income families, the new budget would allow HUD to require what would be a prohibitive minimum
monthly rent payment.
885
Additionally, the budget also eliminated reimbursements for utility payments
and deductions such as child care and medical expenses, used to calculate the share of rent tenants
pay.
886
In a rejection of the Trump administration’s budget proposal, Congress increased funding for
HUD programs through the 2018 Omnibus spending bill.
887
The Omnibus bill expanded overall funding
for HUD programs by 10 percent and represented a 30 percent increase from the president’s budget
proposal.
888
,
889
TRUMP ADMINISTRATION FY2019 BUDGET PROPOSAL
In February 2018, the Trump Administration released its FY2019 budget proposal for HUD. The proposal
would cut overall funding for HUD by $8.8 billion and eliminate programs such as the Public Housing
Capital Fund, and the Community Development Block Grant.
890
Additionally, the proposal detailed plans
to restructure housing assistance programs under HUD, namely the Public Housing, Section 8 Housing
Choice Voucher, and Project-based housing assistance programs, which would include work
requirements.
891
Under the proposal, local Public Housing Authorities and project-based housing owners
would be able to impose work requirements on non-elderly, non-disabled tenants who receive rental
assistance.
892
The details of the work requirement policies would be determined by the HUD secretary,
and agencies would need HUD approval to implement work requirements.
893
In addition to work
requirements, the proposal also detailed plans to increase mandatory and/or minimum rents paid by
tenants, and to limit income verifications for rental assistance to once every three years.
894
MAKING AFFORDABLE HOUSING WORK ACT OF 2018
Early in 2018, the Trump Administration released its FY2019 budget proposal for HUD that included cuts
to the department’s funding, increased rents for housing assistance recipients, and work
requirements.
895
Following the administration’s proposal, HUD released a legislative proposal in April
2018 known as the Making Affordable Housing Work Act (MAHWA), with an aim to have the proposal
introduced as a bill in Congress.
896
The MAHWA proposal broadly aligns with the FY2019 budget
proposal on work requirements and rent increases. Similar to the FY2019 budget proposal, under
MAHWA, PHAs and project-based housing owners would be able to impose work requirements on non-
elderly and non-disabled tenants.
897
The HUD secretary would determine the number of work hours
needed to meet the work requirements, and agencies who did implement work requirements would be
exempt from imposing the community service and self-sufficiency requirements under the 1937
Housing Act.
898
In addition to work requirements, non-elderly, non-disabled families would see their
rents increase from 30 percent to 35 percent of their adjusted income.
899
For families with elderly or
disabled members, their rents would increase to either 30 percent of adjusted income or the minimum
rent of $50, depending on which amount is higher.
900
The proposal also cuts income deductions such
medical or child care expenses, which could be factored in calculating how much rental assistance a
household receives.
901
A hardship exemption from rent increases and work requirements could be
granted to households, “unable to pay the family rent due to a financial hardship,” such as threat of
eviction, job loss, a death in the family, and other circumstances at the discretion of the HUD
secretary.
902
The MAHWA proposal has yet to be taken up by a member in Congress,
903
but, if
implemented, would impact an estimated 175,000 families.
904
FOSTERING STABLE HOUSING OPPORTUNITIES ACT OF 2018
A recent House bill, the Fostering Stable Housing Opportunities Act, would impose work requirements
on youth aging out of the foster care system in order to keep their housing assistance benefits.
905
Under
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the bill, youth who have aged out of foster care and are receiving housing assistance would be required
to either have a high school degree, have a job, or be participating in a career pathway within 30 months
of first receiving housing assistance.
906
While the bill appears well-intentioned in supporting former foster care youth, it could have adverse
effects in the population, due to several challenges and risk-factors associated with foster youth. These
challenges often stem from negative and/or traumatic experiences due to the disruptive life events and
instability many foster youth face.
907
Consequently, many foster youth struggle to successfully transition
into adulthood after aging out of foster care.
908
The bill has not yet advanced.
909
HUD MOVING-TO-WORK DEMONSTRATIONS
First authorized under the 1996 Omnibus Consolidated Rescissions and Appropriations Act, the Moving
to Work (MTW) demonstration program provides PHAs the flexibility to test and implement strategies
for housing assistance reform. Under MTW, qualifying PHAs could change regulations and utilize funding
for public housing and Section 8 housing choice vouchers to implement programs with the aim to
promote economic security among assisted families; achieve programmatic efficiency and reduce costs;
and increase housing choice for low-income households.
910
The 1996 Act authorized MTW
demonstrations for 39 PHAs nationally but in 2015 Congress authorized expansion of MTW to 100
PHAs.
911
To date, nine PHAs have used the MTW demonstration to impose work requirements on
housing assistance recipients.
912
The implementation of MTW programs has varied significantly across
various PHAs and little research exists on the effects of the program on housing assistance. Although
designed as a demonstration, a report by the GAO concluded that, MTW oversight was limited, which
has undermined efforts to effectively evaluate the program’s outcomes and impact.
913
Unsurprisingly,
little is known about the effects of work requirements implemented by the nine PHAs under MTW. Only
one rigorous evaluation on the Charlotte Housing Authority has been conducted,
914
which concluded
that work requirements generated, “modest effects on employment and little impact on income.”
915
HUD PUBLIC HOUSING COMMUNITY SERVICE AND SELF-SUFFICIENCY REQUIREMENT
Under this program, non-elderly and non-disabled families and individuals in public housing are required
to perform eight hours of community service or work-related activities each month.
916
The acceptable
activities include: subsidized and unsubsidized employment; job training, job search and readiness
programs, community service, and educational attainment among other things.
917
There is currently no
federal work requirement for Section 8 Housing Voucher recipients, although some recipients may still
be subject to work requirements through some MTW demonstration sites.
918
Unlike work requirements
programs under SNAP and TANF, there are no time limits placed on public housing recipients subject to
work requirements.
919
However, some PHAs have instituted time limits under the MTW demonstration.
Public housing beneficiaries can be exempt from these work requirements if they are elderly (age 62 and
above), have a disability as defined through SSI or SSDI, are a caretaker of someone with a disability, are
a single parent of a child below one year, or a child under six years if they are unable to obtain child
care.
920
Endnotes
1
Fremstad, Shawn. “Trump’s ‘Public Charge’ Rule Would Radically Change Legal Immigration.” Center for American
Progress, 27 November 2018. Available at
https://www.americanprogress.org/issues/poverty/reports/2018/11/27/461461/trumps-public-charge-rule-
radically-change-legal-immigration/.
2
Parrott, Sharon et al. “Trump Budget Deeply Cuts Health, Housing, Other Assistance for Low- and Moderate-
Income Families.” Center on Budget and Policy Priorities, 14 February 2018. Available at
https://www.cbpp.org/research/federal-budget/trump-budget-deeply-cuts-health-housing-other-assistance-for-
low-and.
3
These proposals include turning Medicaid into a block grant and efforts to move HUD away from its focus on
housing discrimination. See: “Trump Administration Plans Effort to Let States Remodel Medicaid.” Wall Street
Journal, 11 January 2019. Available at https://www.wsj.com/articles/trump-administration-plans-effort-to-let-
states-remodel-medicaid-11547259197 and “Ben Carson is Pulling HUD Away From its Key Mission.” Vox, 11 April
2018. Available at https://www.vox.com/identities/2018/3/8/17093136/ben-carson-hud-discrimination-fair-
housing-anniversary.
4
See for example the discussion of cuts, work requirements, and restructuring of economic security programs
here: Golden, Olivia. “Moving America’s Families Forward: Setting Priorities for Reducing Poverty and Expanding
Opportunity.” Testimony presented to the Committee on Ways and Means, U.S. House of Representatives, 24 May
2016. Available at https://www.clasp.org/sites/default/files/public/resources-and-publications/publication-
1/2016-05-24-Olivia-Golden-Testimony-to-House-Ways-and-Means.pdf.
5
Hoynes, Hilary, Diane Whitmore Schanzenbach, and Douglas Almond. "Long-Run Impacts of Childhood Access to
the Safety Net." American Economic Review, April 2016. Available at
https://gspp.berkeley.edu/assets/uploads/research/pdf/Hoynes-Schanzenbach-Almond-AER-2016.pdf.
6
Bivens, Josh, and Shawn Fremstad. "Why Punitive Work-Hours Tests in SNAP and Medicaid Would Harm Workers
and Do Nothing to Raise Employment." Economic Policy Institute, 26 July 2018. Available at
https://www.epi.org/publication/why-punitive-work-hours-tests-in-snap-and-medicaid-would-harm-workers-and-
do-nothing-to-raise-employment/.
7
Sherman, Arloc, and Tazra Mitchell. "Economic Security Programs Help Low-Income Children Succeed Over Long
Term, Many Studies Find." Center on Budget and Policy Priorities, 17 July 2017. Available at
https://www.cbpp.org/research/poverty-and-inequality/economic-security-programs-help-low-income-children-
succeed-over.
8
Carlson, Steven, and Zoe Neuberger. "WIC Works: Addressing the Nutrition and Health Needs of Low-Income
Families for 40 Years." Center on Budget and Policy Priorities, updated 29 March 2017. Available at
https://www.cbpp.org/research/food-assistance/wic-works-addressing-the-nutrition-and-health-needs-of-low-
income-families.
9
Hoynes et al. "Long-Run Impacts of Childhood Access to the Safety Net." 2016.
10
Sherman, et al. "Economic Security Programs Help Low-Income Children Succeed Over Long Term, Many Studies
Find." 2017.
11
Brown, David W., Amanda E. Kowalski, and Ithai Z. Lurie. "Medicaid as an Investment in Children: What is the
Long-Term Impact on Tax Receipts?" NBER Working Paper No. 20835, January 2015. Available at
https://www.nber.org/papers/w20835.pdf.
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Unworkable & Unwise | 85
12
Chetty, Raj, Nathaniel Hendren, and Lawrence F. Katz. "The Effects of Exposure to Better Neighborhoods on
Children: New Evidence from the Moving to Opportunity Project." American Economic Review 106(4): 855-902,
August 2015. Available at https://pubs.aeaweb.org/doi/pdfplus/10.1257/aer.20150572.
13
Sommers, Benjamin D., and Donald Oellerich. "The poverty-reducing effect of Medicaid." Journal of Health
Economics, 32(5): 816-832, September 2013. Available at
https://www.sciencedirect.com/science/article/pii/S016762961300091X.
14
Fox, Liana. "The Supplemental Poverty Measure: 2016." U.S. Census Bureau, revised September 2017. Available
at https://www.census.gov/content/dam/Census/library/publications/2017/demo/p60-261.pdf.
15
Garfield, Rachel, Robin Rudowitz, and Anthony Damico. “Understanding the Intersection of Medicaid and Work.”
Kaiser Family Foundation, 5 January 2018. Available at https://www.kff.org/medicaid/issue-brief/understanding-
the-intersection-of-medicaid-and-work/.
16
Rudowitz, Robin, and Rachel Garfield. "10 Things to Know about Medicaid: Setting the Facts Straight." Kaiser
Family Foundation, 12 April 2018. Available at https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-
medicaid-setting-the-facts-straight/.
17
"Supplemental Nutrition Assistance Program Participation and Costs." Food and Nutrition Service, U.S.
Department of Agriculture, 7 December 2018. Available at https://fns-
prod.azureedge.net/sites/default/files/pd/SNAPsummary.pdf.
18
Kearney, Melissa S., and Benjamin H. Harris. "Hunger and the Important Role of SNAP as Part of the American
Safety Net." Brookings Institute, 22 November 2013. Available at https://www.brookings.edu/blog/up-
front/2013/11/22/hunger-and-the-important-role-of-snap-as-part-of-the-american-safety-net/.
19
"Policy Basics: Federal Rental Assistance." Center on Budget and Policy Priorities, updated 15 November 2017.
Available at https://www.cbpp.org/research/housing/policy-basics-federal-rental-assistance.
20
Authors’ calculation using data at "Assisted Housing: National and Local." Office of Policy Development and
Research, U.S. Department of Housing and Urban Development, retrieved 17 December 2018. Available at
https://www.huduser.gov/portal/datasets/assthsg.html#2009-2017_query; "Section 521 Rental Assistance:
Households Members." U.S. Department of Agriculture, 6 April 2018. Available at
https://www.rd.usda.gov/files/RDUL-MFHannual.pdf; "U.S. and World Population Clock." U.S. Census Bureau,
updated 25 January 2019. Available at https://www.census.gov/popclock/.
21
Dutta-Gupta, Indi, and Kali Grant. “TANF’s Not All Right.” The Hill, 30 April 2015. Available at
https://thehill.com/opinion/op-ed/240666-tanfs-not-all-right.
22
“In recent decades, a number of states have eliminated their General Assistance programs, while many others
have cut funding, restricted eligibility, imposed time limits, and/or cut benefits.” See Schott, Liz, and Misha Hill.
“State General Assistance Programs Are Weakening Despite Increasing Need.” Center for Budget and Policy
Priorities, 9 July 2015. Available at https://www.cbpp.org/research/family-income-support/state-general-
assistance-programs-are-weakening-despite-increased.
23
Shaefer, H. Luke, et al. "The Decline of Cash Assistance and the Well-Being of Households with Children." Poverty
Solutions at the University of Michigan, 28 August 2018. Available at https://poverty.umich.edu/working-
paper/the-decline-of-cash-assistance-and-the-well-being-of-households-with-children/.
24
Bolen, Ed, and Stacy Dean. “Waivers Add Key State Flexibility to SNAP’s Three-Month Time Limit.” Center for
Budget and Policy Priorities, 6 February 2018. Available at https://www.cbpp.org/research/food-
assistance/waivers-add-key-state-flexibility-to-snaps-three-month-time-limit.
25
Bolen, Ed, et al. “More Than 500,000 Adults Will Lose SNAP Benefits in 2016 as Waivers Expire.” Center for
Budget and Policy Priorities, updated 18 March 2016. Available at https://www.cbpp.org/research/food-
assistance/more-than-500000-adults-will-lose-snap-benefits-in-2016-as-waivers-expire.
26
Paquette, Danielle, and Jeff Stein. "Trump Administration Aims to Toughen Work Requirements for Food Stamp
Recipients." Washington Post, 20 December 2018. Available at
https://www.washingtonpost.com/business/economy/trump-administration-aims-to-toughen-work-
requirements-for-food-stamps-recipients/2018/12/20/cf687136-03e6-11e9-b6a9-
0aa5c2fcc9e4_story.html?noredirect=on.
27
Jan, Tracy. "Trump Wants More People Who Receive Housing Subsidies to Work." Washington Post, 23 May
2017. Available at https://www.washingtonpost.com/news/wonk/wp/2017/05/23/for-the-first-time-poor-people-
receiving-housing-subsidies-may-be-required-to-work/?noredirect=on&utm_term=.a98e8b97d80f.
28
“State Waivers List.” Medicaid.gov, Retrieved 15 January 2019. Available at
https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/index.html.
29
Rosenbaum, Sara. “Stewart v. Azar and the Future of Medicaid Work Requirements.” Commonwealth Fund, 3
July 2018. Available at https://www.commonwealthfund.org/future-of-Medicaid-work-requirements.
30
Hahn, Heather. “Work Requirements in Safety Net Programs: Lessons for Medicaid from TANF and SNAP.” Urban
Institute, April 2018. Available at
https://www.urban.org/sites/default/files/publication/98086/work_requirements_in_safety_net_programs_0.pdf.
31
Author’s calculations. See: “Databases, Tables and Calculators by Subject.” Bureau of Labor Statistics, U.S.
Department of Labor, retrieved 26 January 2019. Available at https://data.bls.gov/timeseries/LNS13327709.
32
“Labor Force Statistics from the Current Population Survey.” Bureau of Labor Statistics, U.S. Department of
Labor, updated 4 January 2019. Available at https://www.bls.gov/web/empsit/cpseea03.htm.
33
“BLS Information: Glossary.” Bureau of Labor Statistics, U.S. Department of Labor, updated 7 June 2016.
Available at https://www.bls.gov/bls/glossary.htm.
34
These workers were either unemployed; employed part-time for economic reasons; or were available for work,
had looked for a job sometime in the prior 12 months (or since the end of their last job if they held one within the
past 12 months), but were not counted as unemployed because they had not searched for work in the prior 4
weeks.
35
“Unemployment Rate: Black or African American (LNS14000006).” Federal Reserve Bank of St. Louis and Bureau
of Labor Statistics, U.S. Department of Labor, retrieved 26 January 2019. Available at
https://fred.stlouisfed.org/series/LNS14000006.
36
Whittaker, Julie M., and Katelin P. Isaacs. “Unemployment Insurance: Programs and Benefits.” Congressional
Research Service, 27 February 2018. Available at https://crsreports.congress.gov/product/pdf/RL/RL33362.
37
“US Business Cycle Expansions and Contractions.” National Bureau of Economic Research (NBER), retrieved 26
January 2019. Available at https://www.nber.org/cycles/cyclesmain.html.
38
Hahn, Heather, et al. “Why Does Cash Welfare Depend on Where You Live? How and Why State TANF Programs
Vary.” Urban Institute, 5 June 2017. Available at https://www.urban.org/research/publication/why-does-cash-
welfare-depend-where-you-live.
39
Ku, Leighton, and Erin Brantley. “Medicaid Work Requirements: Who’s at Risk?" Health Affairs, 12 April, 2017.
Available at https://www.healthaffairs.org/do/10.1377/hblog20170412.059575/full/.
40
Wolkomir, Elizabeth. “How SNAP Can Better Serve the Formerly Incarcerated.” Center on Budget and Policy
Priorities, 16 March 2018. Available at https://www.cbpp.org/research/food-assistance/how-snap-can-better-
serve-the-formerly-incarcerated.
41
“Taking Away Medicaid for Not Meeting Work Requirements Harms Children.” Center on Budget and Policy
Priorities, updated 20 December 2018. Available at https://www.cbpp.org/research/health/harm-to-children-
from-taking-away-medicaid-from-people-for-not-meeting-work.
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42
Page, Marianne. "Safety Net Programs Have Long-term Benefits for Children in Poor Households." Center for
Poverty Research, University of California, Davis, March 2017. Available at
https://poverty.ucdavis.edu/sites/main/files/file-attachments/cpr-health_and_nutrition_program_brief-
page_0.pdf.
43
We refer throughout to “formal” employment, to distinguish it from the very real “informal” employment and
other work, such as caregiving for a family member and attending to one’s own health, that does not result in
earnings and pay reported to the federal government for tax administration and other purposes.
44
We use the term “economic security system” to refer to state and federal programs and policies that are
intended to reduce short-run poverty and hardship, even for higher income households. That system includes
contributory social insurance programs, targeted tax and transfer programs, and other policies primarily intended
to raise and maintain basic living standards of families and low-paid workers.
45
“History of SSA During the Johnson Administration 1963-1968: The Development of Medicare.” Social Security
Administration, retrieved 4 January 2019. Available at https://www.ssa.gov/history/ssa/lbjmedicare1.html.
46
“Historical Background and Development of Social Security.” Social Security Administration, retrieved 4 January
2019. Available at https://www.ssa.gov/history/briefhistory3.html.
47
“Social Security: Unemployment Insurance.” Virginia Commonwealth University School of Social Welfare,
retrieved 4 January 2019. Available at https://socialwelfare.library.vcu.edu/social-security/social-security-
unemployment-insurance/.
48
Hahn, Heather et al. "Work Requirements in Social Safety Net Programs: A Status Report of Work Requirements
in TANF, SNAP, Housing Assistance, and Medicaid." Urban Institute, 22 December 2017. Available at
https://www.urban.org/research/publication/work-requirements-social-safety-net-programs-status-report-work-
requirements-tanf-snap-housing-assistance-and-medicaid.
49
Michel, Sonya. “The History of Child Care in the U.S.” VCU Libraries’ Social Welfare History Project, 2011.
Available at https://socialwelfare.library.vcu.edu/programs/child-care-the-american-history/.
50
To be sure, should an unemployed jobseeker participate in their state’s TANF program, their chance of
benefiting from a child care subsidy should rise. “CCDF Policies Database.” Urban Institute, and Office of Planning,
Research and Evaluation, U.S. Department of Health and Human Services, retrieved 8 January 2019. Available at
https://ccdf.urban.org/search-database.
51
Moffitt, Robert. “The US Safety Net and Work Incentives: Is There a Problem? What Should Be Done?” Included
in Strain, Michael R., ed. The US Labor Market: Questions and Challenges for Public Policy. Washington, D.C.:
American Enterprise Institute, 24 October 2016. Print. Available at http://www.aei.org/wp-
content/uploads/2016/10/The-US-Labor-Market.pdf.
52
“How You Earn Credits.” Social Security Administration, January 2019. Available at
https://www.ssa.gov/pubs/EN-05-10072.pdf.
53
“Disability Benefits.” Social Security Administration, retrieved 3 January 2018. Available at
https://www.ssa.gov/benefits/disability/.
54
Barry, Patricia. “What If I Haven’t Worked Long Enough to Qualify for Medicare?” AARP, April 2014. Available at
https://www.aarp.org/health/medicare-insurance/info-04-2008/ask_ms__medicare_9.html.
55
State Unemployment Insurance Benefits.” Employment and Training Administration, U.S. Department of Labor, 6
June 2018. Available at https://workforcesecurity.doleta.gov/unemploy/uifactsheet.asp.
56
“Do I Qualify for EITC?” Internal Revenue Service, 20 October 2018. Available at https://www.irs.gov/credits-
deductions/individuals/earned-income-tax-credit/do-i-qualify-for-earned-income-tax-credit-eitc.
57
Huang, Chye-Ching. “Final CTC Changes Don’t Alter Tax Bill Basics: 10 Million Working Family Children Get Little
or Nothing.” Center for Budget and Policy Priorities, 15 December 2017. Available at
https://www.cbpp.org/blog/final-ctc-changes-dont-alter-tax-bill-basics-10-million-working-family-children-get-
little-or.
58
“Tax Reform: The Child Credit and the Child Care Credit.” Congressional Research Service, 13 November 2017.
Available at https://www.everycrsreport.com/reports/IN10816.html.
59
Adams, Gina. “A Historic Boost to Child Care Funding Means States Can Start to Realize the Potential of the Child
Care and Development Block Grant.” Urban Institute, 15 February 2018. Available at
https://www.urban.org/urban-wire/historic-boost-child-care-funding-means-states-can-start-realize-potential-
child-care-and-development-block-grant.
60
To be sure, should an unemployed jobseeker participate in their state’s TANF program, their chance of
benefiting from a child care subsidy should rise. “CCDF Policies Database.” Urban Institute, and Office of Planning,
Research and Evaluation, U.S. Department of Health and Human Services, 2019.
61
Hahn, Heather, et al. “Work Requirements in Social Safety Net Programs: A Status Report of Work Requirements
in TANF, SNAP, Housing Assistance, and Medicaid.” Urban Institute, December 2017. Available at
https://www.urban.org/sites/default/files/publication/95566/work-requirements-social-safety-net-
programs_4.pdf.
62
“State Waivers List.” Medicaid.gov, 2019.
63
Rada, Rosa. “SNAP Work Requirements Fact Sheet.” National Conference of State Legislatures, 16 May 2018.
Available at http://www.ncsl.org/research/human-services/snap-work-requirements-fact-sheet.aspx.
64
Paquette, et al. “Trump Administration Aims to Toughen Work Requirements for Food Stamps Recipients.”2018.
65
See: “Work Requirements Tracker.” Urban Institute, updated 24 January 2019. Available at
https://www.urban.org/features/work-requirements-tracker.
66
“FY 2019 Congressional Justifications: Enhance Rental Assistance.” U.S. Department of Housing and Urban
Development, 12 February 2018. Available at
https://www.hud.gov/press/press_releases_media_advisories/HUD_No_18_012.
67
Cove Delisle, Elizabeth, Rachel Austin, and H. Samuel Papenfuss. “H.R. 2069 Fostering Stable Housing
Opportunities Act of 2018.” Congressional Budget Office Cost Estimate, 11 September 2018. Available at
https://www.cbo.gov/system/files?file=2018-09/hr2069.pdf.
68
For evidence of poverty reduction from housing assistance, see Fischer, Will. "Research Shows Housing Vouchers
Reduce Hardship and Provide Platform for Long-Term Gains Among Children." Center on Budget and Policy
Priorities, updated 7 October 2015. Available at https://www.cbpp.org/research/housing/research-shows-housing-
vouchers-reduce-hardship-and-provide-platform-for-long-term; for Medicaid’s antipoverty effects, see
Wagnerman, Karina. “Research Update: Medicaid Pulls Americans Out of Poverty, Updated Edition.” Georgetown
University Center for Children and Families, 8 March 2018. Available at
https://ccf.georgetown.edu/2018/03/08/research-update-medicaid-pulls-americans-out-of-poverty-updated-
edition/; for poverty reduction from SNAP see Wheaton, Laura, and Victoria Tran. "The Antipoverty Effects of the
Supplemental Nutrition Assistance Program." Urban Institute, February 2018. Available at
https://www.urban.org/sites/default/files/publication/96521/the_antipoverty_effects_of_the_supplemental_nutr
ition_assistance_program_2.pdf.
69
Fenelon, Andrew, et al. “Housing Assistance Programs and Adult Health in the United States.” American Journal
of Public Health, 107(4): 571-578, April 2017. Available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5343706/; see also: Fenelon, Andrew, et al. “The Impact of
Housing Assistance on the Mental Health of Children in the United States.” Journal of Health and Social Behavior,
59(3): 447-463, 1 September 2018. Available at
https://journals.sagepub.com/doi/full/10.1177/0022146518792286.
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Unworkable & Unwise | 89
70
West, Rachel. "Expanding Medicaid in All States Would Save 14,000 Lives Per Year." Center for American
Progress, 24 October 2018. Available at
https://www.americanprogress.org/issues/healthcare/reports/2018/10/24/459676/expanding-medicaid-states-
save-14000-lives-per-year/.
71
By increasing financial insecurity and material hardship, for example.
72
“House Farm Bill’s SNAP Cuts, Work Requirements Would Hurt Children.” Center on Budget and Policy Priorities,
updated 6 July 2018. Available at https://www.cbpp.org/research/food-assistance/house-farm-bills-snap-cuts-
work-requirements-would-hurt-children.
73
“Expanding Work Requirements in Non-Cash Welfare Programs.” The Council of Economic Advisers, July 2018.
Available at https://www.whitehouse.gov/wp-content/uploads/2018/07/Expanding-Work-Requirements-in-Non-
Cash-Welfare-Programs.pdf; See also: Hahn, Heather, et al. “Work Requirements in Social Safety Net Programs.”
Urban Institute, December 2017. Available at https://www.urban.org/sites/default/files/publication/95566/work-
requirements-in-social-safety-net-programs.pdf.
74
Bauer, et al. "Work Requirements and Safety Net Programs." 2018.
75
In this study, participants who are able to work are defined as “nonelderly adults who do not receive SSI and are
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In this study, participants who are able to work are defined as “a working-age, non-disabled adult.” "Policy
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If households spend “more than 30 percent of their income for housing,” they are considered “cost-burdened”
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Author's calculations based on "Table 1: People in the Labor Force: Poverty Status and Work Experience, By
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In 2016, six percent of people working in the labor force were below the poverty level, of which 47.6 percent
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Child care, in particular, is already difficult to afford and find, especially when it is needed during non-work
hours or on short notice. Many families may then rely on informal arrangements. Both informal and formal care
can be difficult to arrange on short notice if a parent’s work schedule changes. See Enchautegui, Maria E.
“Nonstandard Work Schedules and the Well-Being of Low-Income Families.” Urban Institute, July 2013. Available
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Enchautegui. “Nonstandard Work Schedules and the Well-Being of Low-Income Families.” 2013.
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Lambert. “Passing the Buck: Labor Flexibility Practices That Transfer Risk onto Hourly Workers.” 2008.
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Lambert. “Passing the Buck: Labor Flexibility Practices That Transfer Risk onto Hourly Workers.” 2008.
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more-from-medicaid-over-work-requirements-2371457; See also: “Arkansas Works Program: November 2018
Report.” Arkansas Department of Human Services, November 2018. Available at
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f.
235
Mitchell, Tazra, LaDonna Pavetti, and Yixuan Huang. “Study Praising Kansas’ Harsh TANF Work Penalties is
Fundamentally Flawed.” Center on Budget and Policy Priorities, 20 February 2018. Available at
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fundamentally.
236
Mitchell, et al. “Study Praising Kansas’ Harsh TANF Work Penalties is Fundamentally Flawed.” 2018.
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237
Mitchell, et al. “Study Praising Kansas’ Harsh TANF Work Penalties is Fundamentally Flawed.” 2018.
238
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience.” 2017.
239
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Solomon, Judith, and Aviva Aron-Dine. “Non-Expansion States Can’t Fix Catch 22 in Their Proposals to Take
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Solomon, et al. “Non-Expansion States Can’t Fix Catch 22 in Their Proposals to Take Medicaid Coverage Away
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242
Solomon, et al. “Non-Expansion States Can’t Fix Catch 22 in Their Proposals to Take Medicaid Coverage Away
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243
Hahn, et al. “Work Requirements in Social Safety Net Programs.” 2017; Garfield, et al. "Implications of Work
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244
Bauer, Lauren, and Diane Whitmore Schanzenbach. “Who Loses SNAP Benefits If Additional Work Requirements
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ed_workers.
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Garfield, et al. “Understanding the Intersection of Medicaid and Work.” 2018.
246
Yentel, Diane. “Point of View: HUD Plans to Increase Rents and Impose Work Requirements.” National Low
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rents-and-impose-work-requirements-diane-yentel-nlihc.
247
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience. Brief” 2017.
248
See for example, “Expanding Work Requirements in Non-Cash Welfare Programs.” The Council of Economic
Advisers, 2018.
249
Thus far, there has been no rigorous evaluations of programs that operate under TANF’s rules and on a high
scale. See: Falk, Gene. “Research Evidence on the Impact of Work Requirements in Need-Tested Programs.”
Congressional Research Service, 20 September 2018. Available at https://fas.org/sgp/crs/misc/R45317.pdf.
250
Falk. “Research Evidence on the Impact of Work Requirements in Need-Tested Programs.” 2018.
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Falk. “Research Evidence on the Impact of Work Requirements in Need-Tested Programs.” 2018.
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Pavetti. "Work Requirements Don’t Cut Poverty, Evidence Shows." 2016.
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Falk. “Research Evidence on the Impact of Work Requirements in Need-Tested Programs.” 2018.
254
Falk. “Research Evidence on the Impact of Work Requirements in Need-Tested Programs.” 2018.
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256
Hahn, et al. “Work Requirements in Social Safety Net Programs.” 2017.
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Antonisse, Larisa, and Rachel Garfield. “The Relationship Between Work and Health: Findings from a Literature
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259
The majority of work-eligible recipients surveyed were either already working or seeking employment.
Sommers, Benjamin D., et al. “New Approaches in Medicaid: Work Requirements, Health Savings Accounts, and
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260
The majority of work-eligible recipients surveyed were either already working or seeking employment.
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Access.” 2018.
261
Yentel. “Point of View: HUD Plans to Increase Rents and Impose Work Requirements.” 2018.
262
Garfield, et al. “Understanding the Intersection of Medicaid and Work.” 2018.
263
These include mental and physical health conditions, lack of access to transportation, lack of child care services,
discrimination, caregiving responsibilities, criminal justice system involvement, skills and education gaps, and
limited economic opportunity, among others. Dutta-Gupta, et al. “Lessons Learned from 40 Years of Subsidized
Employment Programs.” 2016.
264
Pavetti. "Work Requirements Don’t Cut Poverty, Evidence Shows." 2016.
265
Dutta-Gupta, et al. “Lessons Learned from 40 Years of Subsidized Employment Programs.” 2016.
266
Pavetti, LaDonna. “Evidence Doesn’t Support Claims of Success of TANF Work Requirements.” Center on Budget
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267
Ku, et al. “Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?” 2018.
268
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Falk et al. “Work Requirements, Time Limits, and Work Incentives in TANF, SNAP, and Housing Assistance.”
2016.
272
Musumeci, MaryBeth, Rachel Garfield, and Robin Rudowitz. “Medicaid and Work Requirements: New Guidance,
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273
In this paper, “Medicaid demonstration projects” refer to states’ proposals to implement work requirements
under Medicaid’s Section 1115 guidelines. For more information, refer to Appendix A.
274
Ku, et al. “Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?” 2018.
275
Falk et al. “Work Requirements, Time Limits, and Work Incentives in TANF, SNAP, and Housing Assistance.”
2016.
276
Ku, et al. “Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?” 2018.
277
Ku, et al. “Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?” 2018.
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278
Rocha, Renato and Anna Cielinski. “Why the Current Workforce System is Not Suited to Help Medicaid
Beneficiaries Meet Work Requirements.” Center for Law and Social Policy, 31 October 2018. Available at
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requirements.
279
Pavetti, LaDonna and Liz Schott. “House Bill to Reauthorize TANF Makes Improvements but Doesn’t Go Far
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280
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience. Brief” 2017.
281
Hahn, et al. “Work Requirements in Social Safety Net Programs.” 2017.
282
Sherman, Arloc. “After 1996 Welfare Law, a Weaker Safety Net and More Children in Deep Poverty.” Center on
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283
For the original evaluation, see: Freedman, Stephen, et al. “National Evaluation of Welfare-to-Work Strategies:
Evaluating Alternative Welfare-to-Work Approaches: Two-Year Impacts for Eleven Programs.” U.S. Department of
Health and Human Services and U.S. Department of Education, June 2000. Available at
https://www.mdrc.org/sites/default/files/full_93.pdf; For the calculation used in this paper, see: Sherman, Arloc.
"Work Requirements for Cash Assistance Fueled Rise in Deep Poverty." Center for Budget and Policy Priorities, 13
November 2018. Available at https://www.cbpp.org/blog/work-requirements-for-cash-assistance-fueled-rise-in-
deep-poverty.
284
Hamilton, Gayle, and Charles Michalopoulos. “Job Search or Basic Education Participation First: Which Improves
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https://www.mdrc.org/sites/default/files/NEWWS-final-Web.pdf.
285
Hamilton, et al. “Job Search or Basic Education Participation First: Which Improves Welfare Recipients’ Earnings
More in the Long Term?” 2016.
286
Floyd, Ife, Ashley Burnside, and Liz Schott. “TANF Reaching Few Poor Families.” Center on Budget and Policy
Priorities, 13 December 2017. Available at https://www.cbpp.org/research/family-income-support/tanf-reaching-
few-poor-families.
287
Fagan, Patrick, and Robert Rector. “The Continuing Good News About Welfare Reform.” The Heritage
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288
Germanis, Peter. “Will Work Requirements Reduce Poverty? A Response to Robert Doar.” MLWiseman.com, 16
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Reduce-Poverty.pdf.
289
Germanis. “Will Work Requirements Reduce Poverty? A Response to Robert Doar.” 2018.
290
Freedman, et al. “National Evaluation of Welfare-to-Work Strategies: Evaluating Alternative Welfare-to-Work
Approaches: Two-Year Impacts for Eleven Programs.” 2000; Pavetti. "Work Requirements Don’t Cut Poverty,
Evidence Shows." 2016.
291
Falk, Gene, Maggie McCarty, and Randy Alison Aussenberg “Work Requirements, Time Limits, and Work
Incentives in TANF, SNAP, and Housing Assistance.” Congressional Research Service, 9 November 2016. Available at
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292
Moffitt, Robert A., “Economics of Means-Tested Transfer Programs in the United States, Volume 1.” National
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293
Hahn, et al. “Work Requirements in Social Safety Net Programs: A Status Report of Work Requirements in TANF,
SNAP, Housing Assistance, and Medicaid.” 2017.
294
Scally, Corianne Payton, et al. "The Case for More, Not Less: Shortfalls in Federal Housing Assistance and Gaps in
Evidence for Proposed Policy Changes." Urban Institute, 3 January 2018. Available at
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295
Growing the share of people with the lowest incomes necessarily increases income inequality, all other things
being equal.
296
Sherman. “After 1996 Welfare Law, a Weaker Safety Net and More Children in Deep Poverty.” 2016.
297
Pavetti. "Work Requirements Don’t Cut Poverty, Evidence Shows." 2016.
298
Freedman, et al. “National Evaluation of Welfare-to-Work Strategies: Evaluating Alternative Welfare-to-Work
Approaches: Two-Year Impacts for Eleven Programs.” 2000.
299
“Deep poverty rates rose by a statistically significant amount in six of the 11 programs — and didn’t fall
significantly in any — relative to randomly assigned control groups.” See Sherman. "Work Requirements for Cash
Assistance Fueled Rise in Deep Poverty." 2018.
300
Shaefer, H. Luke, and Kathryn Edin. “Rising Extreme Poverty in the United States and the Response of Federal
Means-Tested Transfer Programs.” Social Service Review 87(2): 250-268, June 2013. Available at
https://www.journals.uchicago.edu/doi/10.1086/671012.
301
Sherman. “After 1996 Welfare Law, a Weaker Safety Net and More Children in Deep Poverty.” 2016.
302
Shaefer, et al. “Rising Extreme Poverty in the United States and the Response of Federal Means-Tested Transfer
Programs.” 2013.
303
Sherman. “After 1996 Welfare Law, a Weaker Safety Net and More Children in Deep Poverty.” 2016.
304
Sherman. “After 1996 Welfare Law, a Weaker Safety Net and More Children in Deep Poverty.” 2016.
305
Sherman. “After 1996 Welfare Law, a Weaker Safety Net and More Children in Deep Poverty.” 2016.
306
Sherman. “After 1996 Welfare Law, a Weaker Safety Net and More Children in Deep Poverty.” 2016.
307
Sherman. "Work Requirements for Cash Assistance Fueled Rise in Deep Poverty." 2018.
308
Sherman. “After 1996 Welfare Law, a Weaker Safety Net and More Children in Deep Poverty.” 2016.
309
Hahn, et al. “Work Requirements in Social Safety Net Programs.” 2017.
310
Pavetti, LaDonna. “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work.” 2018.
311
Pavetti, LaDonna. “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work.” 2018.
312
Pavetti, LaDonna. “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work.” 2018.
313
Pavetti, LaDonna. “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work.” 2018.
314
Schott, Liz, and LaDonna Pavetti. “Changes in TANF Work Requirements Could Make Them More Effective in
Promoting Employment.” Center on Budget and Policy Priorities, 26 February 2013. Available at
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more-effective-in.
315
Pavetti, LaDonna. “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work.” 2018.
316
Pavetti, LaDonna. “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work.” 2018.
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317
Lens, Vicki. “Work Sanctions Under Welfare Reform: Are They Helping Women Achieve Self-Sufficiency.” Duke
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Hasenfeld, Yeheskel, Toorji Ghose, and Kandyce Larson. "The Logic of Sanctioning Welfare Recipients: An
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319
Hahn, et al. “Work Requirements in Social Safety Net Programs.” 2017.
320
Greene. “Medicaid Recipients’ Early Experience with the Arkansas Medicaid Work Requirement.” 2018.
321
Greene. “Medicaid Recipients’ Early Experience with the Arkansas Medicaid Work Requirement.” 2018.
322
Ku, et al. “Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?” 2018.
323
Goldstein, Amy. “An Experiment Requiring Work for Food Stamps is a Trump Administration Model.”
Washington Post, 29 November 2018. Available at https://www.washingtonpost.com/national/health-science/an-
experiment-requiring-work-for-food-stamps-is-a-trump-administration-model/2018/11/29/edeaf5c4-db83-11e8-
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324
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience. Brief.” 2017.
325
For example, with Medicaid, federal Centers for Medicare and Medicaid Services (CMS) guidelines give states
broad flexibility in how they administer work requirements. Gleckman, Howard. “What Medicaid's Work
Requirement Means for Seniors, People with Disabilities, And Their Caregivers.” Forbes, 19 January 2018. Available
at https://www.forbes.com/sites/howardgleckman/2018/01/19/what-medicaids-work-requirement-means-for-
seniors-people-with-disabilities-and-their-caregivers/#5d6ead36206c.
326
Schott, et al. “Changes in TANF Work Requirements Could Make Them More Effective in Promoting
Employment.” 2013.
327
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience.” 2017.
328
Herd, Pamela. “How Administrative Burdens Are Preventing Access to Critical Income Supports for Older Adults:
The Case of the Supplemental Nutrition Assistance Program.” Public Policy and Aging Report, 25(2): 52-55, 20 June
2015. Available at https://academic.oup.com/ppar/article/25/2/52/1501759.
329
Davis, Andy. “2 Who Lost Medicaid Join Lawsuit; 4 Other Enrollees Are Added as Plaintiffs in Work-Rule Case.”
Arkansas Democrat-Gazette, 6 November 2018. Available at
https://www.arkansasonline.com/news/2018/nov/06/2-who-lost-medicaid-join-lawsuit-201811-1/.
330
Such blanket requirements command blanket-usage of resources: they are devoted to participants equally,
regardless of need. This lack of targeting resources means they do less marginal good for people with fewer needs
or barriers, and do not go far enough for others who require more intensive support. See: Ku, et al. “Medicaid
Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?” 2018.
331
Wikle. “Medicaid Works: No Work Requirement Necessary—Frequently Asked Questions about Medicaid and
Work Requirements.” 2018.
332
Katch, Hannah, Jennifer Wagner, and Aviva Aron-Dine. “Taking Away Coverage from People Not Meeting Work
Requirements Will Reduce Low-Income Families’ Access to Care and Worsen Health Outcomes.” Center on Budget
and Policy Priorities, updated 13 August 2018. Available at https://www.cbpp.org/research/health/medicaid-work-
requirements-will-reduce-low-income-families-access-to-care-and-worsen.
333
Sanger-Katz. “Hate Paperwork? Medicaid Recipients Will Be Drowning in it.” 2018.
334
Wikle. “Medicaid Works: No Work Requirement Necessary—Frequently Asked Questions about Medicaid and
Work Requirements.” 2018.
335
Hahn, et al. “Work Requirements in Social Safety Net Programs.” 2017.
336
Hahn, et al. “Work Requirements in Social Safety Net Programs.” 2017.
337
Gleckman. “What Medicaid’s Work Requirement Means for Seniors, People with Disabilities, and Their
Caregivers." 2018.
338
Keane. “Medicaid Work Requirements: The Impact on Family Caregivers and Older Adults.” Justice in Aging,
2018.
339
Katch, et al. “Taking Medicaid Coverage Away from People Not Meeting Work Requirements Will Reduce Low-
Income Families’ Access to Care and Worsen Health Outcomes.” 2018.
340
Katch, et al. “Taking Medicaid Coverage Away from People Not Meeting Work Requirements Will Reduce Low-
Income Families’ Access to Care and Worsen Health Outcomes.” 2018.
341
“An Early Look at State Data for Medicaid Work Requirements in Arkansas.” Kaiser Family Foundation, 22
August 2018. Available at https://www.kff.org/report-section/an-early-look-at-state-data-for-medicaid-work-
requirements-in-arkansas-issue-brief/.
342
“An Early Look at State Data for Medicaid Work Requirements in Arkansas.” Kaiser Family Foundation, 2018.
343
Kean. “Medicaid Work Requirements: The Impact on Family Caregivers and Older Adults.” Justice in Aging,
2018.
344
“Internet/Broadband Fact Sheet.” Pew Research Center, 5 February 2018. Available at
http://www.pewinternet.org/fact-sheet/internet-broadband/.
345
Rudowitz, Robin, MaryBeth Musumeci, and Cornelia Hall. “Year End Review: December State Data for Medicaid
Work Requirements in Arkansas.” Kaiser Family Foundation, 17 January 2019. Available at
https://www.kff.org/medicaid/issue-brief/state-data-for-medicaid-work-requirements-in-arkansas/.
346
Gangopadhyaya, Anuj, et al. “Under Medicaid Work Requirements, Limited Internet Access in Arkansas May Put
Coverage at Risk.” Urban Institute, 29 October 2018. Available at https://urbn.is/2CPq1xa.
347
Gangopadhyaya, et al. “Under Medicaid Work Requirements, Limited Internet Access in Arkansas May Put
Coverage at Risk.” 2018.
348
Rampell, Catherine. “Are Medicaid Work Requirements Inherently, Irredeemably Flawed?” Daytona Beach
News-Journal, 26 November 2018. Available at https://www.news-
journalonline.com/opinion/20181126/catherine-rampell-are-medicaid-work-requirements-inherently-
irredeemably-flawed.
349
Arkansas originally made the decision to make reporting online-only in an effort to circumvent hiring additional
staff. See: Rampell, Catherine. “Arkansas Says It Wants to Help the Poor. It’s Hurting Them Instead.” Washington
Post, 20 November 2018. Available at https://www.washingtonpost.com/opinions/arkansas-says-it-wants-to-help-
the-poor-its-hurting-them-instead/2018/11/19/8e61f0a2-ec3c-11e8-96d4-
0d23f2aaad09_story.html?utm_term=.12b1fd6aede6.
350
Wikle, Suzanne. “Medicaid Works: No Work Requirement Necessary—Frequently Asked Questions about
Medicaid and Work Requirements.” 2018.
351
Derr, Michelle K., and Elizabeth Brown. “Improving Program Engagement of TANF Families: Understanding
Participation and Those with Reported Zero Hours of Participation in Work Activities.” Mathematica Policy
Research, 19 January 2015. Available at
https://www.acf.hhs.gov/sites/default/files/opre/engagement_and_zero_hours_report_12_19_14.pdf; Casey,
Timothy. “The Sanction Epidemic in the Temporary Assistance for Needy Families Program.” Legal Momentum,
retrieved 26 January 2019. Available at https://www.legalmomentum.org/sites/default/files/reports/sanction-
epidemic-in-tanf.pdf.
352
Hahn, et al. “Work Requirements in Social Safety Net Programs.” 2017.
353
Bauer, et al. "Work Requirements and Safety Net Programs." 2018.
Working Paper
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354
“Kentucky Official Downplays Concern about New Medicaid Rules.” Associated Press, 27 November 2018.
Available at https://www.wkyt.com/content/news/Kentucky-official-downplays-concern-about-new-Medicaid-
rules-501388791.html.
355
“Medicaid Work Requirements That Exempt Native American Tribe Members Approved for Arizona.” Kaiser
Health News, 22 January 2019. Available at https://khn.org/morning-breakout/medicaid-work-requirements-that-
exempt-native-american-tribe-members-approved-for-arizona/.
356
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience.”2017.
357
Within the U.S., there is no unanimous definition of disability. Nevertheless, definitions generally coalesce
around it being a physical, mental, or sensory impairment that impedes basic life activities. In 2010, the Census
Bureau estimated that nearly 1 in 5 (19 percent) people in the U.S. civilian noninstitutionalized population had a
disability, defined as a “physical or mental impairment that affects one or more major life activities, such as
walking, bathing, dressing, eating, preparing meals, doing errands alone or doing housework.” Brault, Matthew.
“Americans with Disabilities: 2010.” U.S. Census Bureau, July 2012. Available at
https://www.census.gov/library/publications/2012/demo/p70-131.html.
358
Musumeci, MaryBeth, Julia Foutz, and Rachel Garfield. "How Might Medicaid Adults with Disabilities Be
Affected by Work Requirements in Section 1115 Waiver Programs?" Kaiser Family Foundation, 26 January 2018.
Available at https://www.kff.org/medicaid/issue-brief/how-might-medicaid-adults-with-disabilities-be-affected-
by-work-requirements-in-section-1115-waiver-programs/.
359
Gleckman. “What Medicaid’s Work Requirement Means for Seniors, People with Disabilities, and Their
Caregivers." 2018.
360
Neale, Brian. "Letter to State Medicaid Director RE: Opportunities to Promote Work and Community
Engagement Among Medicaid Beneficiaries." Centers for Medicare and Medicaid Services, 11 January 2018.
Available at https://www.medicaid.gov/federal-policy-guidance/downloads/smd18002.pdf.
361
Gangopadhyaya, Anuj, and Genevieve M. Kenney. "Who Could Be Affected by Kentucky’s Medicaid Work
Requirements, and What Do We Know About Them?" Urban Institute, updated 26 March 2018. Available at
https://www.urban.org/research/publication/updated-who-could-be-affected-kentuckys-medicaid-work-
requirements-and-what-do-we-know-about-them.
362
Gangopadhyaya, et al. "Who Could Be Affected by Kentucky’s Medicaid Work Requirements, and What Do We
Know About Them?" 2018.
363
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience.”2017. See
also Parrott, Sharon. “The New TANF Requirements and Individuals with Disabilities.” Center on Budget and Policy
Priorities, 1 March 2007. Available at http://www.cbpp.org/research/the-new-tanf-requirements-and-individuals-
with-disabilities.
364
Pavetti, LaDonna, Michelle Derr, and Emily Sama Martin. “Assisting TANF Recipients Living with Disabilities to
Obtain and Maintain Employment: Conducting In-Depth Assessments.” Mathematica Policy Research, February
2008. Available at https://www.acf.hhs.gov/sites/default/files/opre/conducting_in_depth.pdf.
365
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience.”2017; See
also Pavetti, et al. “Assisting TANF Recipients Living with Disabilities to Obtain and Maintain Employment:
Conducting In-Depth Assessments.” 2008.
366
Loprest, Pamela. “Disconnected Welfare Leavers Face Serious Risks.” Urban Institute, 2002. Available at
http://www.urban.org/sites/default/files/publication/59036/310839-Disconnected-Welfare-Leavers-Face-Serious-
Risks.PDF.
367
“Taking Away Medicaid for Not Meeting Work Requirements Harms Children.” Center on Budget and Policy
Priorities, 2018.
368
Garfield, et al. "Implications of Work Requirements in Medicaid: What Does the Data Say?" 2018.
369
Aron-Dine,et al. “Many Working People Could Lose Health Coverage Due to Medicaid Work Requirements.”
2018.
370
Goddard, James, et al. "State Options in Expanding Access to Education in TANF Programs." Clearinghouse
Community, Sargent Shriver National Center on Poverty Law, October 2016. Available at
http://povertylaw.org/files/docs/article/ClearinghouseCommunity_October_2.pdf.
371
Hall, Randi. “Expanding Education and Training Opportunities Under TANF: A Path to Stable Employment in
Today's Economy.” Center for Law and Social Policy, July 2016. Available at
https://www.clasp.org/sites/default/files/public/resources-and-publications/publication-1/07.2016-Expanding-
Education-and-Training-Opportunities-under-TANF.pdf.
372
Katch, Hannah. "Medicaid Work Requirement Would Limit Health Care Access Without Significantly Boosting
Employment." Center on Budget and Policy Priorities, 13 July 2016. Available at:
https://www.cbpp.org/research/health/medicaid-work-requirement-would-limit-health-care-access-without-
significantly.
373
New York exempts people who have applied for SSI and are waiting to hear back about their eligibility
determination from TANF work requirements. See: Parrott, Sharon. “The New TANF Requirements and Individuals
with Disabilities.” Center on Budget and Policy Priorities, 1 March 2007. Available at
https://www.cbpp.org/research/the-new-tanf-requirements-and-individuals-with-disabilities.
374
Musumeci, MaryBeth, Robin Rudowitz, and Cornelia Hall. “An Early Look at Implementation of Medicaid Work
Requirements in Arkansas.” Kaiser Family Foundation, October 2018. Available at
http://files.kff.org/attachment/Issue-Brief-An-Early-Look-at-Implementation-of-Medicaid-Work-Requirements-in-
Arkansas.
375
Wikle. “Medicaid Works: No Work Requirement Necessary--Frequently Asked Questions about Medicaid and
Work Requirements.” 2018.
376
Loprest, Pamela. “Disconnected Welfare Leavers Face Serious Risks.” 2002.
377
Antonisse, et al. “The Effects of Medicaid Expansion Under the ACA: Updated Findings from a Literature
Review.” 2018.
378
Katch, et al. “Taking Medicaid Coverage Away from People Not Meeting Work Requirements Will Reduce Low-
Income Families’ Access to Care and Worsen Health Outcomes.” 2018.
379
Garfield, et al. “Implications of a Medicaid Work Requirement: National Estimates of Potential Coverage
Losses.” 2018; This trend holds true for SNAP as well. See: Bauer, et al. “Health Conditions Keep Many SNAP
Participants Out of the Labor Force.” 2018.
380
Pavetti, LaDonna. “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work.” 2018.
381
Pavetti, LaDonna. “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work.” 2018.
382
Schott, et al. “Changes in TANF Work Requirements Could Make Them More Effective in Promoting
Employment.” 2013.
383
"Fitch: Medicaid Waiver Actions Limit US States' Cost Controls." Fitch Ratings, 17 July 2018. Available at
https://public.medicaid.gov/gf2.ti/af/328098/47497/PDF/-/Combined_Evidence_1115_Waiver_2.pdf.
384
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience.”2017.
385
Ku, et al. “Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?” 2018.
386
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience.”2017.
387
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience.”2017.
Working Paper
Unworkable & Unwise | 107
388
For example, some state Medicaid agencies have voluntarily made modest employment-supporting programs
available to enrollees with disabilities, not employment-requiring programs. See Musumeci, et al. “Medicaid
Enrollees and Work Requirements: Lessons from the TANF Experience.”2017.
389
“State Medicaid programs are set up as health coverage programs, in most cases overseeing private health
plans that manage and deliver medical and long-term care services.” Musumeci, et al. “Medicaid Enrollees and
Work Requirements: Lessons from the TANF Experience.”2017.
390
Neale, Brian. "Letter to Medicaid Director RE: Opportunities to Promote Work and Community Engagement
Among Medicaid Beneficiaries." 2018.
391
Goldberg, Heidi. “Summary: A Compliance-Oriented Approach to Sanctions in State and County TANF
Programs.” Center on Budget and Policy Priorities, 28 March 2001. Available at https://www.cbpp.org/archives/3-
28-01tanf.htm.
392
Pavetti, LaDonna. “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work.” 2018.
393
Neale, Brian. "Letter to Medicaid Director RE: Opportunities to Promote Work and Community Engagement
Among Medicaid Beneficiaries." 2018.
394
Falk et al. “Work Requirements, Time Limits, and Work Incentives in TANF, SNAP, and Housing Assistance.”
2016.
395
Falk et al. “Work Requirements, Time Limits, and Work Incentives in TANF, SNAP, and Housing Assistance.”
2016.
396
Falk et al. “Work Requirements, Time Limits, and Work Incentives in TANF, SNAP, and Housing Assistance.”
2016.
397
Pavetti, LaDonna. “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work.” 2018.
398
Neale, Brian. "Letter to Medicaid Director RE: Opportunities to Promote Work and Community Engagement
Among Medicaid Beneficiaries." 2018.
399
Pavetti, LaDonna. “TANF Studies Show Work Requirement Proposals for Other Programs Would Harm Millions,
Do Little to Increase Work.” 2018.
400
For more about potential issues with exemptions, see report section, ‘Revoking Participation in Work-
Supporting Programs due to Rigid & Impractical Work Requirements Is Inefficient for All.’
401
Ku, et al. “Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?” 2018.
402
Ku, et al. “Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?” 2018.
403
Falk et al. “Work Requirements, Time Limits, and Work Incentives in TANF, SNAP, and Housing Assistance.”
2016.
404
Li, Linda, et al. “Policy Brief: Weighing the Cost Savings of Medicaid Work Requirements in a Non-Expansion
State.” Center for Health Economics and Policy, Institute for Public Health at Washington University, May 2018.
Available at https://publichealth.wustl.edu/wp-content/uploads/2018/06/MO-Medicaid-Work-Fiscal-Brief-
final.pdf.
405
Falk et al. “Work Requirements, Time Limits, and Work Incentives in TANF, SNAP, and Housing Assistance.”
2016.
406
Yetter, Deborah. “Bevin’s Medicaid Changes Actually Mean Kentucky Will Pay More to Provide Health Care.”
Louisville Courier-Journal, 14 February 2018. Available at https://www.courier-
journal.com/story/news/politics/2018/02/14/kentucky-medicaid-changes-bevin-work-requriements/319384002/.
407
“Part of the administrative costs added to this year's budget would go toward creating a Medicaid computer
system required by the federal government.” See Yetter. “Bevin’s Medicaid Changes Actually Mean Kentucky Will
Pay More to Provide Health Care.” 2018.
408
Yetter. “Bevin’s Medicaid Changes Actually Mean Kentucky Will Pay More to Provide Health Care.” 2018.
409
Sommers, et al. “New Approaches in Medicaid; Work Requirements, Health Savings Accounts, and Health Care
Access.” 2018.
410
Katch. "Medicaid Work Requirement Would Limit Health Care Access Without Significantly Boosting
Employment." 2016.
411
Gehr, et al. “Doubling Down: How Work Requirements in Public Benefit Programs Hurt Low-Wage Workers.”
2017.
412
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience. Brief” 2017.
413
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience. Brief” 2017.
414
Gehr, et al. “Doubling Down: How Work Requirements in Public Benefit Programs Hurt Low-Wage Workers.”
2017.
415
Schott, et al. “Changes in TANF Work Requirements Could Make Them More Effective in Promoting
Employment.” 2013.
416
Musumeci, et al. “Medicaid Enrollees and Work Requirements: Lessons from the TANF Experience.” 2017.
417
Ku, et al. “Medicaid Work Requirements: Will They Help the Unemployed Gain Jobs or Improve Health?” 2018.
418
Rosenbaum, Dottie. “House Farm Bill’s SNAP Changes Are a Bad Deal for States and Low-Income Households.”
Center on Budget and Policy Priorities, 15 May 2018. Available at https://www.cbpp.org/research/food-
assistance/house-farm-bills-snap-changes-are-a-bad-deal-for-states-and-low-income.
419
“Cost Estimate of H.R. 2, Agriculture and Nutrition Act of 2018.” Congressional Budget Office, 2 May 2018.
Available at https://www.cbo.gov/system/files?file=2018-07/hr2_1.pdf.
420
“Cost Estimate of H.R. 2, Agriculture and Nutrition Act of 2018.” Congressional Budget Office, 2018.
421
Haught, Randy, Allen Dobson, and Phap-Hoa Luu. “The Potential Financial Impact of Medicaid Work
Requirement on Kentucky Hospitals.” The Commonwealth Fund, 1 November 2018. Available
at https://www.commonwealthfund.org/blog/2018/potential-financial-impact-medicaid-work-requirement-
kentucky-hospitals.
422
Rudowitz, Robin, and Rachel Garfield. “New Analysis Shows States with Medicaid Expansion Experienced
Declines in Uninsured Hospital Discharges.” Kaiser Commission on Medicaid and the Uninsured, Kaiser Family
Foundation, September 2015. Available at http://files.kff.org/attachment/issue-brief-new-analysis-shows-states-
with-medicaid-expansion-experienced-declines-in-uninsured-hospital-discharges.
423
Haught, et al. “The Potential Financial Impact of Medicaid Work Requirement on Kentucky Hospitals.” 2018.
424
Brown, et al. "Medicaid as an Investment in Children: What is the Long-Term Impact on Tax Receipts?" 2015.
425
Brown, et al. "Medicaid as an Investment in Children: What is the Long-Term Impact on Tax Receipts?" 2015.
426
“Taking Away Medicaid for Not Meeting Work Requirements Harms Children.” Center on Budget and Policy
Priorities, 2018.
427
“The Tax Policy Center’s Briefing Book.” Tax Policy Center, retrieved 23 January 2019. Available at
https://www.taxpolicycenter.org/briefing-book/what-are-automatic-stabilizers-and-how-do-they-work.
428
West, Rachel, et al. "Strengthening Unemployment Protections in America." Georgetown Center on Poverty and
Inequality, Center for American Progress, and National Employment Law Project, 16 June 2016. Available at
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429
West, et al. "Strengthening Unemployment Protections in America." 2016.
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Unworkable & Unwise | 109
430
Glied, Sherry A., and Sara Snowden. "Adding a Work Requirement to Medicaid Could Hurt Kentucky’s
Economy." The Commonwealth Fund, 9 April 2018. Available at
https://www.commonwealthfund.org/blog/2018/adding-work-requirement-medicaid-could-hurt-kentuckys-
economy.
431
“Kentucky is responsible for 28.8 percent of Medicaid spending for those eligible for coverage prior to the ACA.
For those eligible for coverage under the ACA, Kentucky’s share will rise from 6 percent in 2018 to 7 percent in
2019 and to 10 percent in 2020 and beyond.” Glied, et al. "Adding a Work Requirement to Medicaid Could Hurt
Kentucky’s Economy." 2018.
432
“In 2018, Arkansas will pay just 6 percent of the cost of Medicaid for expansion enrollees, rising to 7 percent in
2019 and to 10 percent in 2020 and beyond. Moreover, Arkansas residents pay a relatively small share (just 1.1%)
of the federal taxes that cover the federal cost of the program.” Glied, Sherry A. "How a Medicaid Work
Requirement Could Affect Arkansas’s Economy." The Commonwealth Fund, 31 October 2018. Available at
https://www.commonwealthfund.org/blog/2018/medicaid-work-requirement-arkansas-economy.
433
Glied. "How a Medicaid Work Requirement Could Affect Arkansas’s Economy." 2018.
434
“Overall, lost federal funding will eclipse reduced state spending by a magnitude of 8.6 to 1.” Glied. "How a
Medicaid Work Requirement Could Affect Arkansas’s Economy." 2018.
435
Glied. "How a Medicaid Work Requirement Could Affect Arkansas’s Economy." 2018.
436
Glied, et al. "Adding a Work Requirement to Medicaid Could Hurt Kentucky’s Economy." 2018.
437
Glied, et al. "Adding a Work Requirement to Medicaid Could Hurt Kentucky’s Economy." 2018.
438
Glied, et al. "Adding a Work Requirement to Medicaid Could Hurt Kentucky’s Economy." 2018.
439
Glied, et al. "Adding a Work Requirement to Medicaid Could Hurt Kentucky’s Economy." 2018.
440
Grant, et al. “Security and Stability: Paid Family and Medical Leave and its Importance to People with Disabilities
and their Families.” 2017.
441
“The Stealth Attack on Women’s Health: Medicaid Work Requirements Would Reduce Access to Care for
Women Without Increasing Employment.” National Women’s Law Center, 2017.
442
"Taking Away Medicaid for Not Meeting Work Requirements Harms People with Disabilities." Center on Budget
and Policy Priorities, updated 10 December 2018. Available at https://www.cbpp.org/research/health/taking-
away-medicaid-for-not-meeting-work-requirements-harms-people-with.
443
Vallas, Rebecca, Shawn Fremstad, and Lisa Ekman. “A Fair Shot for Workers with Disabilities.” Center for
American Progress, 28 January 2015. Available at https://www.americanprogress.org/issues/poverty/
reports/2015/01/28/105520/a-fair-shot-for-workers-with-disabilities/.
444
Vallas, et al. “A Fair Shot for Workers with Disabilities.” 2015.
445
Houtenville, et al. “2015 National Employment and Disability Survey: Report of Main Findings.” 2015.
446
Grant, et al. “Security and Stability: Paid Family and Medical Leave and its Importance to People with Disabilities
and their Families.” 2017.
447
Grant, et al. “Security and Stability: Paid Family and Medical Leave and its Importance to People with Disabilities
and their Families.” 2017.
448
This includes a majority of younger and older participants who would be subject to work requirements.
“Crucially, this analysis already excludes program participants who reported disability income because they would
be eligible for a categorical exemption from a work requirement.” Bauer, et al. “Health Conditions Keep Many
SNAP Participants Out of the Labor Force.” 2018.
449
Ku, et al. “Medicaid Work Requirements: Who’s at Risk?" 2017.
450
Bailey, et al. “Medicaid Work Requirements Don’t Protect People with Disabilities.” 2018.
451
Grant, et al. “Security and Stability: Paid Family and Medical Leave and its Importance to People with Disabilities
and their Families.” 2017.
452
"Taking Away Medicaid for Not Meeting Work Requirements Harms People with Disabilities." Center on Budget
and Policy Priorities, updated 10 December 2018. Available at https://www.cbpp.org/research/health/taking-
away-medicaid-for-not-meeting-work-requirements-harms-people-with.
453
Badger, Emily, and Margot Sanger-Katz. “Which Poor People Shouldn’t Work for Aid?” New York Times, 15 May
2018. Available at https://www.nytimes.com/2018/05/15/upshot/medicaid-poor-michigan-work-
requirements.html.
454
Scott. “How Medicaid Work Requirements Can Exempt Rural Whites but Not Urban Blacks.” 2018.
455
McDaniel, Marla, et al. “Identifying Racial and Ethnic Disparities in Human Services: A Conceptual Framework
and Literature Review.” Urban Institute, November 2017. Available at
https://www.acf.hhs.gov/sites/default/files/opre/identifying_racial_and_ethnic_disparities_b508.pdf.
456
Hahn, et al. “Why Does Cash Welfare Depend on Where You Live? How and Why State TANF Programs Vary.”
2017.
457
Monnat, Shannon M. “The Color of Welfare Sanctioning: Exploring the Individual and Contextual Roles of Race
on TANF Case Closures and Benefit Reductions.” Sociological Quarterly, 51(4): 678-707, 5 October 2010. Available
at https://onlinelibrary.wiley.com/doi/full/10.1111/j.1533-8525.2010.01188.x.
458
Fontenot, Kayla, Jessica Semega, and Melissa Kollar. “Income and Poverty in the United States: 2017.” U.S.
Census Bureau, 12 September 2018. Available at https://www.census.gov/library/publications/2018/demo/p60-
263.html.
459
Hahn. “Work Requirements in Safety Net Programs: Lessons for Medicaid from TANF and SNAP.” 2018.
460
Hahn, et al. “Why Does Cash Welfare Depend on Where You Live? How and Why State TANF Programs Vary.”
2017.
461
Updated from Hahn, Heather. Statement for hearing on “Strengthening Access and Accountability to Work in
Welfare Programs.” U.S. House of Representative Committee on Education and the Workforce, Subcommittee on
Higher Education and Workforce Development, 15 March 2018. Available at
https://www.urban.org/sites/default/files/publication/97216/strengthening_access_and_accountability_to_work_
in_welfare_programs.pdf.
462
In June 2018, the state unemployment rate (5.7 percent) was higher than the national average (4.2 percent),
and most of Mississippi’s counties with the lowest employment and economic development levels were majority
African American. See Waxman, Elaine. “Mississippi’s Work Requirements Don’t Account for a Varying Labor
Market by Race and Geography.” Urban Institute, 18 October 2018. Available at https://www.urban.org/urban-
wire/mississippis-work-requirements-dont-account-varying-labor-market-race-and-geography.
463
Waxman. “Mississippi’s Work Requirements Don’t Account for a Varying Labor Market by Race and Geography.”
2018.
464
Monnat. “The Color of Welfare Sanctioning: Exploring the Individual and Contextual Roles of Race on TANF Case
Closures and Benefit Reductions.” 2010.
465
McDaniel, et al. “Identifying Racial and Ethnic Disparities in Human Services: A Conceptual Framework and
Literature Review.” 2017.
466
Monnat. “The Color of Welfare Sanctioning: Exploring the Individual and Contextual Roles of Race on TANF Case
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Sullivan, Peter. “Federal Panel Warns of People Losing Health Coverage in Arkansas from Work Requirement.”
The Hill, 8 November 2018. Available at https://thehill.com/policy/healthcare/415771-federal-commission-warns-
of-people-losing-health-coverage-in-arkansas-from.
724
Sullivan. “Federal Panel Warns of People Losing Health Coverage in Arkansas from Work Requirement.” 2018.
725
Brantley, Max. “Lawsuit Challenges Arkansas’ Medicaid Work Rule.” Arkansas Times, 14 August 2018. Available
at https://www.arktimes.com/ArkansasBlog/archives/2018/08/14/lawsuit-challenges-arkansass-medicaid-work-
rule.
726
Goldberg. “Arkansas Drops 4,600 More from Medicaid Over Work Requirements.” 2018.
727
Neale. “Letter to Medicaid Director RE: Opportunities to Promote Work and Community Engagement Among
Medicaid Beneficiaries.” Centers for Medicare and Medicaid Services, U.S. Department of Health and Human
Services. 2018.
728
Hardy, Benjamin. “Is Arkansas’s Work Requirement Rule Working?” Arkansas Times, 5 November, 2018.
Available at https://www.arktimes.com/arkansas/is-arkansas-works-working/Content?oid=25231088.
729
“Medicaid Demonstrations: Evaluations Yielded Limited Results, Underscoring Need for Changes to Federal
Policies and Procedures.” Government Accountability Office, 19 January 2018. Available
at https://www.gao.gov/assets/690/689506.pdf.
730
Gillespie. “Bevin Says He’ll End Expanded Medicaid if Courts Block His Changes.” 2018.
731
Beam. “Trump Administration Approves Kentucky Medicaid Work Requirement Waiver.” 2018.
732
Gillespie. “Bevin Says He’ll End Expanded Medicaid if Courts Block His Changes.” 2018.
733
“Letter to Carol H. Steckel, Commissioner, Kentucky Department of Medicaid Services.” Office of the
Administrator Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services, 20
November 2018. Available at https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Waivers/1115/downloads/ky/ky-health-ca.pdf.
734
Gillespie. “Bevin Says He’ll End Expanded Medicaid if Courts Block His Changes.” 2018.
735
Gangopadhyaya, et al. "Who Could Be Affected by Kentucky’s Medicaid Work Requirements, and What Do We
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736
“Letter to Carol H. Steckel, Commissioner, Kentucky Department of Medicaid Services.” Office of the
Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services. 2018.
737
Collins et al. "The Potential Implications of Work Requirements for the Insurance Coverage of Medicaid
Beneficiaries: The Case of Kentucky." 2018.
738
Collins et al. "The Potential Implications of Work Requirements for the Insurance Coverage of Medicaid
Beneficiaries: The Case of Kentucky." 2018.
739
Musumeci et al. “An Early Look at Implementation of Medicaid Work Requirements in Arkansas.” 2018.
740
Brantley et al. “A First Glance at Medicaid Work Requirements in Arkansas: More Than One-Quarter Did Not
Meet Requirement.” 2018.
741
Wagner, Jennifer. “Commentary: As Predicted, Arkansas’ Medicaid Waiver is Taking Coverage Away from
Eligible People.” Center on Budget and Policy Priorities, 18 December 2018. Available at
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eligible-people#_ftn1.
742
“Arkansas Works: Work and Community Engagement Requirements, Medicaid Section 1115 Demonstration
Project, Work Requirement Evaluation Design and Strategy.” Arkansas Department of Human Services, amended
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Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-cmmnty-
engagement-draft-eval-dsgn-20180813.pdf.
743
“Arkansas Works: Work and Community Engagement Requirements, Medicaid Section 1115 Demonstration
Project, Work Requirement Evaluation Design and Strategy.” Arkansas Department of Human Services. 2018.
744
Brantley et al. “A First Glance at Medicaid Work Requirements in Arkansas: More Than One-Quarter Did Not
Meet Requirement.” 2018.
745
“Arkansas Works: Work and Community Engagement Requirements, Medicaid Section 1115 Demonstration
Project, Work Requirement Evaluation Design and Strategy.” Arkansas Department of Human Services. 2018.
746
“Arkansas Works: Work and Community Engagement Requirements, Medicaid Section 1115 Demonstration
Project, Work Requirement Evaluation Design and Strategy.” Arkansas Department of Human Services. 2018.
747
“Arkansas Works: Work and Community Engagement Requirements, Medicaid Section 1115 Demonstration
Project, Work Requirement Evaluation Design and Strategy.” Arkansas Department of Human Services. 2018.
748
“Arkansas Works: Work and Community Engagement Requirements, Medicaid Section 1115 Demonstration
Project, Work Requirement Evaluation Design and Strategy.” Arkansas Department of Human Services. 2018.
749
Brantley et al. “A First Glance at Medicaid Work Requirements in Arkansas: More Than One-Quarter Did Not
Meet Requirement.” 2018.
750
Rudowitz et al. “Year End Review: December State Data for Medicaid Work Requirements in Arkansas.” 2019.
751
Galewitz, Phil. “Indiana Adds Work Requirement to Medicaid, Will Block Coverage if Paperwork is Late.” NPR, 2
February 2018. Available at https://www.npr.org/sections/health-shots/2018/02/02/582828039/indiana-adds-
work-requirement-to-medicaid-will-block-coverage-if-paperwork-is-la.
752
Russell, John. “Debate Rages Over Medicaid Work Rules as State Rollout Nears.” Indianapolis Business Journal,
14 September 2018. Available at https://www.ibj.com/articles/70476-debate-rages-over-medicaid-work-rules-as-
state-rollout-nears.
753
“Letter to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration.” Office of the
Deputy Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human
Services, 1 February 2018. Available at https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-ca.pdf.
754
“Letter to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration.” Office of the
Deputy Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human
Services. 2018.
755
“Letter to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration.” Office of the
Deputy Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human
Services. 2018.
756
Goldstein, Amy. “Indiana Wins Federal Permission to Adopt Medicaid Work Requirements.” Washington Post, 3
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permission-to-adopt-medicaid-work-requirements/2018/02/02/f681ccae-02cf-11e8-8acf-
ad2991367d9d_story.html?noredirect=on&utm_term=.07d7cd745a66.
757
Indiana’s Managed Care Organizations’ Employment Initiatives, See: “Letter to Allison Taylor, Medicaid Director,
Indiana Family and Social Services Administration.” Office of the Deputy Administrator, Centers for Medicare and
Medicaid Services, U.S. Department of Health and Human Services. 2018.
758
English as a Second Language, See: “Letter to Allison Taylor, Medicaid Director, Indiana Family and Social
Services Administration.” Office of the Deputy Administrator, Centers for Medicare and Medicaid Services, U.S.
Department of Health and Human Services. 2018.
Working Paper
Unworkable & Unwise | 127
759
Gateway to Work, See: “Letter to Allison Taylor, Medicaid Director, Indiana Family and Social Services
Administration.” Office of the Deputy Administrator, Centers for Medicare and Medicaid Services, U.S. Department
of Health and Human Services. 2018.
760
“Letter to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration.” Office of the
Deputy Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human
Services. 2018.
761
Letter to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration. Office of the
Deputy Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human
Services. 2018.
762
“Letter to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration.” Office of the
Deputy Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human
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763
“Letter to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration.” Office of the
Deputy Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human
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764
“Letter to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration.” Office of the
Deputy Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human
Services. 2018.
765
“Letter to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration.” Office of the
Deputy Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human
Services. 2018.
766
“Letter to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration.” Office of the
Deputy Administrator, Centers for Medicare and Medicaid Services. 2018.
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Galewitz. “Indiana Adds Work Requirement to Medicaid, Will Block Coverage if Paperwork is Late.” 2018.
768
Galewitz. “Indiana Adds Work Requirement to Medicaid, Will Block Coverage if Paperwork is Late.” 2018.
769
Russell. “Debate Rages Over Medicaid Work Rules as State Rollout Nears.” 2018.
770
Weixel, Nathaniel. “New Hampshire Wins Approval for Medicaid Work Requirements.” The Hill, 7 May 2018.
Available at https://thehill.com/policy/healthcare/medicaid/386566-new-hampshire-wins-approval-to-imose-
medicaid-work-requirements.
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"1115 Medicaid Waivers in New Hampshire." Families USA, retrieved 7 January 2019. Available at
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"1115 Medicaid Waivers in New Hampshire." Families USA. 2019.
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Schubel, Jessica. "Despite Mounting Evidence of Harm, New Hampshire Poised to Impose Harsh Medicaid Work
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mounting-evidence-of-harm-new-hampshire-poised-to-impose-harsh-medicaid-work-rules.
774
Hodder, Lucy. "Stewart v. Azar- What Does It Mean For New Hampshire’s Medicaid Work and Community
Engagement Requirement?" University of New Hampshire School of Law, 26 July 2018. Available at
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775
"CMS Special Terms and Conditions for New Hampshire Granite Advantage Health Care Program 1115
Demonstration -- 11-W-00298/1." Centers for Medicare and Medicaid Services, 30 November 2018. Available at
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776
Schubel. "Despite Mounting Evidence of Harm, New Hampshire Poised to Impose Harsh Medicaid Work Rules."
2018.
777
Mayhew, Mary C. "New Hampshire Granite Advantage Health Care Program - Demonstration Approval." Center
for Medicaid and CHIP Services, 30 November 2018. Available at https://www.medicaid.gov/Medicaid-CHIP-
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Ramer, Holly. "NH Bipartisan Panel Objects Trump Tweaks to Medicaid Rules." Concord Monitor, 20 December
2018. Available at https://www.concordmonitor.com/N-H-bipartisan-panel-objects-Trump-tweaks-to-Medicaid-
rules-22302048.
782
Wright, Patty. “Maine Could Soon Implement Work Requirements for Medicaid.” Maine Public Radio: Public
Affairs, 22 December 2018. Available at http://www.mainepublic.org/post/maine-could-soon-implement-work-
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783
Starkey, Shelley. “Trump Administration Approves Medicaid Work Requirements in Maine, Michigan.” National
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Hellmann, Jessie. “Trump Administration Approves Medicaid Work Requirements in Michigan, Maine.” The Hill,
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785
Hellmann. “Trump Administration Approves Medicaid Work Requirements in Michigan, Maine.” 2018.
786
“Letter to Tom Price, U.S. Secretary of Health and Human Services, RE: MaineCare 115 Demonstration Project
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787
Starkey. “Trump Administration Approves Medicaid Work Requirements in Maine, Michigan.” 2019.
788
Norris, Louise. “Maine and the ACA’s Medicaid Expansion.” Healthinsurance.org, 3 January 2019. Available at
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789
“Letter to Tom Price, U.S. Secretary of Health and Human Services, RE: MaineCare 115 Demonstration Project
Application.” Maine Department of Health and Human Services. 2017.
790
“Letter to Tom Price, U.S. Secretary of Health and Human Services, RE: MaineCare 115 Demonstration Project
Application.” Maine Department of Health and Human Services. 2017.
791
“The Main Effect of LePage’s, Trump’s Medicaid Work Rules? Fewer People with Coverage.” Bangor Daily News,
12 January 2018. Available at https://bangordailynews.com/2018/01/12/opinion/editorials/the-main-effect-of-
lepages-trumps-medicaid-work-rules-fewer-people-with-coverage/.
792
Lawlor, Joe. “Maine Would Be Among First States to Impose Work Requirements, Premiums on Medicaid
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Musumeci et al. “Proposed Medicaid Section 1115 Waivers in Maine and Wisconsin.” 2017.
794
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Starkey. “Trump Administration Approves Medicaid Work Requirements in Maine, Michigan.” 2019.
796
“Letter to Alex Azar, Secretary of the U.S. Department of Health and Human Services.” State of Michigan,
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_Clean-Web_Posting_632189_7.pdf.
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“Letter to Alex Azar, Secretary of the U.S. Department of Health and Human Services.” State of Michigan,
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Goldman, Maya. “Medicaid Work Requirements Could Affect 700,000 People.” Michigan Radio, 26 June 2018.
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Bouffard, Karen. “Michigan Seeks Federal Approval for Medicaid Work Requirements.” The Detroit News, 10
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Lawler, Emily. “Five Ways Proposed Medicaid Work Requirements Could Affect Michiganders.” MLive, 23 April
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805
“Section 1115 BadgerCare Reform Demonstration Waiver FAQs.” Wisconsin Department of Health Services,
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cla.htm.
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824
Formerly known as Food Stamps, the program has been renamed and no longer involves physical stamps –
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updated 7 December 2018. Available at https://fns-
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828
Under SNAP, a person is considered disabled if they meet any of the following criteria: receive SSI, Social
Security disability or blindness payments; receive a disability retirement benefit from a government agency;
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838
This was changed to 12 percent in the House Farm Bill. “ABAWD 15 Percent Exemptions.” Food and Nutrition
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