North Carolina Health News by Jaymie Baxley
With President Donald Trump back in power, a Republican-led push for work requirements for Medicaid is gaining momentum.
In recent days, Republican governors in South Carolina, Arkansas and Ohio have sought permission from the federal government to kick jobless beneficiaries off their states’ rolls. Russell T. Vought, nominated by Trump to lead the U.S. Office of Management and Budget, expressed support for making coverage conditional on employment during his Senate confirmation hearing — a policy championed in the Project 2025 blueprint he co-authored for the conservative Heritage Foundation think tank.
Supporters of the policy believe work requirements will significantly reduce federal spending on Medicaid, which provides health insurance to about 80 million Americans. But critics contend that tying eligibility to employment will only exacerbate health care inequities in low-income communities and place undue strain on the state agencies that administer the program.
“If you are of the belief, like I am, that Medicaid’s purpose is to get you healthy so that maybe you can work, and you already understand that a lot of people who can work already are working if they have Medicaid, then work requirements are just an additional barrier,” said Ciara Zachary, an assistant professor at the University of North Carolina’s Gillings School of Global Public Health. “It’s not something that helps people’s health, and it’s certainly not going to get more people in the workplace in jobs that help them thrive.”
Zachary said work requirements could also undermine North Carolina’s “hugely successful” expansion of Medicaid, which raised the maximum allowed income for eligibility to 135 percent of the federal poverty level, or just under $36,000 annually for a family of three.
More than 600,000 residents who previously made too much money to qualify for Medicaid have gained coverage since expansion launched in December 2023, swelling the state’s total enrollment to more than 3 million.
“I think it will be harmful, but depending on the perspective, if you’re trying to cut back on Medicaid spending, then you might say it’s actually successful,” Zachary said. “But if folks lose Medicaid, then they’re going to have to get their health care somewhere else. This could burden our urgent care or our emergency rooms and charity care organizations. We all know what that looked like before expansion in the state and the benefits that expansion has had on North Carolina.”
So as the state legislature returns to Raleigh to start its long work session, decisions made in Washington, D.C., will likely shape the debate in North Carolina about what Medicaid will look like in the future.
Where do lawmakers stand?
A list of spending proposals that was recently shared among members of the federal House Budget Committee estimated that Medicaid work requirements would save taxpayers $100 billion over the next 10 years.
But state Rep. Donny Lambeth, a Winston-Salem Republican who co-chairs the Joint Legislative Oversight Committee on Medicaid in the North Carolina legislature, is skeptical of that assessment. He noted that about 73 percent of Medicaid participants who joined the state’s rolls under expansion are currently employed.
“I think it’s way overestimated, the value of that, because so many of our people that we signed up were already working anyway,” he said.
North Carolina was the 40th state to expand Medicaid under the Affordable Care Act. Lambeth said lawmakers in some of the holdout states have been impressed with North Carolina’s decision to pass expansion with a provision to create a workforce development program for beneficiaries.
The program, which is expected to go live next year, was conceived as an optional alternative to work requirements. Enrollees who choose to participate will receive job training and access to career planning services, according to a proposal drafted by the University of North Carolina’s School of Government.
Still, Lambeth acknowledged that a full-blown work mandate is likely to garner more support from Republicans on Capitol Hill.
“Our caucus certainly expects, if there’s a work requirement, that there be some adjustment to include a work requirement,” he said. “I don’t have a big problem with it unless it takes people out [who are] already covered.”
Our twice-weekly email will help you understand how health policy U.S. Rep. Virginia Foxx (NC-5), whose congressional district has the largest percentage of Medicaid enrollees relative to its population in North Carolina, co-sponsored a 2023 bill in the U.S. House of Representatives that would require adult beneficiaries to work or perform community service for at least 80 hours a month to remain enrolled in the program. Her fellow Republicans David Rouzer (NC-7) and Richard Hudson (NC-9) voted in favor of the bill, which included exemptions for beneficiaries who are physically unable to work or are enrolled at least part-time in school.