Trump embraced a conservative vision for Medicaid. States want to try it again

Republicans in half a dozen states have a request for a second Trump administration: Require low-income adults to work for free government health care.

In places like Idaho, Missouri and South Dakota, GOP officials are laying the groundwork to substantially overhaul their health safety-net programs. Their plans, if approved by a Trump White House, could cut hundreds of thousands of people from a program that conservatives have long complained is bloated — but the move could also save states and the federal government billions of dollars.

“Here in South Dakota, we value hard work. For those who are able-bodied, we want to incentivize work, not government entitlement,” said South Dakota Senate Majority Leader Casey Crabtree, a Republican. “We want to be in a position, should there be a change [in the White House] — and hopefully there’s change — that we can implement that.”

The Trump administration authorized 13 states’ work requirements, which tied Medicaid to employment, though only Arkansas’ got off the ground. More than 18,000 people were removed from the rolls in that state before a U.S. District Court judge blocked the program in 2019 and the Biden administration revoked states’ approvals, effectively stifling efforts nationwide.

But the Supreme Court, which never heard the issue, has since added another conservative jurist, and that gives some Republicans hope that their plan, if approved in a second Trump term, would prevail.

“I do think this Supreme Court is more favorable to uphold” work requirements, said Ohio state Sen. Steve Huffman, the Republican chair of the Senate health committee.

Ohio state Sen. Steve Huffman speaks during a hearing, Nov. 17, 2021, in Columbus, Ohio.

The Trump campaign did not respond to a request for comment, and the former president has not discussed the policy on the trail.

Still, work requirements are among the many health priorities outlined in the 2025 presidential blueprint mapped out by the Heritage Foundation and other conservative groups.

Nina Owcharenko Schaefer, director of the Heritage Foundation’s Center for Health and Welfare Policy, said the states’ moves on work requirements demonstrate continued interest in the policy and could encourage a future Trump administration to take another look at it.

“It shows that [states] are being proactive, and they’re not just behind the scenes, waiting to see what happens,” Schaefer said. “That’s signaling to Congress and a new administration that yes, we are still interested in pursuing this, can we get it back on track?”

But some conservatives, including former Trump officials, aren’t sure that reviving the work requirements debate is worth the headache. A new round of protracted legal challenges would almost certainly arise, consuming the time and energy federal health officials could spend on other priorities.

“Medicaid work requirements took a lot of bandwidth at HHS, and it didn’t work out. So, do you want to run the same play, knowing that the courts weighed in the way that they did and that there’s so many other problems that in my view are more glaring than work requirements?” said Brian Blase, a former Trump administration official who is now president of the conservative Paragon Health Institute. “Even if Trump were to get elected, work requirements are definitely not a sure thing.”

And not all Republican governors are on board with this latest push. Spokespeople for Tennessee Gov. Bill Lee and Oklahoma Gov. Kevin Stitt said their states aren’t pursuing work requirements right now, and Utah’s Medicaid agency said there’s been no movement on the policy since 2021. Virginia Gov. Glenn Youngkin’s office did not make anyone available to comment.

Still, many Republicans see reduced enrollment and cost savings as a benefit of the policy, with the Congressional Budget Office determining a federal work requirement would result in 1.5 million people losing federal funding for their coverage and save the federal government $109 billion over a decade.

The proposals vary but generally require Medicaid recipients to work 80 hours a month — or attend school, volunteer or participate in another kind of community engagement activity — with exceptions for certain people, like those who are pregnant, disabled or elderly.

Democrats argue that many people enrolled in Medicaid are already working and requiring people to provide proof will create more paperwork hurdles in an already complex program where people are prone to falling through bureaucratic cracks.

But Republican lawmakers are pitching the policy first and foremost as a way to encourage people to work as states grapple with low labor participation rates, though rates are higheramong the 25- to 54-year-olds many of those states hope to target.

“Hopefully, it would be able to fill some of the employment void,” Huffman said. “People don’t get the benefit if people don’t want to follow the rules … It’s our best attempt to get people out there and, hopefully, at some point move them off Medicaid.”

Ohio’s latest budget requires the state to ask the federal government again to approve work requirements next February, though a long-pending appeal of its 2018 plan remains before federal health officials. Dan Tierney, a spokesperson for Republican Gov. Mike DeWine, said the administration would support moving forward with work requirements even if the budget hadn’t mandated it.

By far, the furthest state along is Arkansas. Republican Gov. Sarah Huckabee Sanders, Trump’s former press secretary, last year directed the state’s Medicaid agency to apply for a new work requirement waiver, which has been pending before CMS since June.

“This proposal is a workforce development program designed to create meaningful ways for Medicaid expansion beneficiaries to move from depending on government health insurance coverage to economic independence through accessing private sector marketplace or employee-sponsored health insurance,” said Gavin Lesnick, a spokesperson for Arkansas’ Medicaid agency.

Other Republican governors are making similar plans. Idaho Gov. Brad Little’s budget proposal released in January includes work requirements.

A spokesperson for South Carolina Gov. Henry McMaster told POLITICO the governor would “certainly” pursue the policy if a Republican wins the White House. And Louisiana Gov. Jeff Landry has indicated an openness to work requirements, though he didn’t include funding for the policy in his budget.

In Missouri and South Dakota, lawmakers hope to ask voters in November to allow work requirements. Both states approved Medicaid expansion through a constitutional referendum and can only amend the program through another ballot measure.

South Dakota’s Republican supermajority Senate in January approved putting the proposal on the ballot, and Crabtree expects the measure, which he sponsored, to move “very quickly” through the House.

“The voters overwhelmingly supported Medicaid expansion. Since that passed on the ballot, we have been dutifully implementing Medicaid expansion here in South Dakota,” he said. “What we’re doing is just coming back to the voters and asking them for clarity.”