shows map of which of the 50 states have chosen to expand medicaid, which have implemented work requirements, and non expansion states
Current status of Medicaid expansion decisions. Map, data courtesy: Kaiser Family Foundation

By Rose Hoban

It’s been in. It’s been out. It’s been rumored. And it’s been confirmed that lawmakers, as they’ve crafted this year’s state budget, have considered adding work requirements for adults receiving Medicaid.

That concerns advocates who argue that adding work rules to the joint state and federal program that provides health care for more than 2.1 million North Carolinians could affect coverage for tens of thousands of people.

Sen. Ralph Hise
Sen. Ralph Hise (R-Spruce Pine)

The policy particularly concerns people who work in the disability community.

“People who need it, they could get pushed out of the program,” said Craig Blevins, who heads the North Carolina Association of the Deaf.

There’s been a lot of talk nationwide about adding work requirements to Medicaid since January when the Trump Administration allowed states to add them for the first time since passage of the federal law that created the program in 1965.

“It’s something that I’ve been advocating for for a long time,” said Sen. Ralph Hise (R-Spruce Pine). “As I go across my district and talk to business owners, I hear they’re desperate for workforce and they’re willing to do things like provide transportation in order to get workers.”

pie chart showing what participat
Labor force participation, disability status, and other community engagement among working-age Medicaid beneficiaries. “CMS requires that states requesting 1115 Waivers that impose work /community engagement requirements must, in complying with the Americans with Disabilities Act (ADA) and other civil rights laws, ‘ensure that individuals with disabilities are not denied Medicaid for inability to meet these requirements, and have mechanisms in place to ensure that reasonable modifications are provided to people who need them.’” Quote, chart courtesy: Steve Kaye, UCSF Community Living Policy Center, How do disability and poor health impact proposed Medicaid work requirements?

He said that getting Medicaid recipients to work would “set people on the road to independence and help move people from government dependency.”

He also said that there would be exceptions for pregnant women, and children, and for folks who have disabilities, are blind, or are too old to work.

Able-bodied adults who are on the program would, however, be affected.

Two programs

Right now, it makes sense to think of Medicaid as two programs, said Matt Salo, head of the National Association of Medicaid Directors.

“There’s the traditional program that serves the very low income, the frail, the sick, the elderly, pregnant women and kids,” he said. “And then there’s the expansion, which is largely working age adults.”

That expansion Salo talked about is the broadening of the program that was written into the Affordable Care Act. This would allow for low-income working adults, such as farmers, janitors, fishermen and many other self-employed laborers who make too much currently to qualify for Medicaid, to become part of the program.

North Carolina has not expanded Medicaid, although some Republican lawmakers in the House of Representatives have filed a bill that would make that possible.

So, the work requirements that might show up in the state budget that lawmakers are working on behind closed doors this week would apply to that “traditional” program.

Few, if any, able-bodied adults qualify for Medicaid right now in North Carolina. A childless adult is simply ineligible unless they are disabled, or are too old or too sick to work. The only non-disabled adults who qualify for benefits are caregivers in a family of three (or more) that earns less than 43 percent of the federal poverty level, about $500 a month.

“It is a major policy,” said Rep. Donny Lambeth (R-Winston-Salem). “Although the president came out and allowed states that have done expansion to do this, we have not done expansion.”

headshot of older white man with mustache and glasses
Rep. Donny Lambeth (R-Winston-Salem) Image courtesy of the NC General Assembly website

Lambeth is one of the sponsors of a Republican expansion plan which would include a work requirement for the low-income workers who would be swept into Medicaid if North Carolina expanded. But he lamented that the bill, “has not gained much traction.”

“I personally don’t think we should take up a work requirements bill until we address the bigger issue, which is, how do we take care of the hundreds of thousands of people that are in the gap … that need help.”

When asked Thursday if the work requirements provision was still in the budget, Lambeth looked at his watch.

“You never know,” he said. “Things change from one minute to the next.”


“There’s a lot of issues that need to be worked out before we try to implement that,” said Rep. Josh Dobson (R-Nebo), who had a line of advocates going in and out of his office all morning Thursday.

Dobson, who is among the sponsors of the Republican’s expansion plan, said he’s opposed to adding the work requirements now.

“There’s a lot of issues that need to be worked out before we try to implement that and it just adds another level of volatility,” he said, noting that North Carolina is already asking federal officials at the Centers for Medicare and Medicaid Services to approve North Carolina’s conversion to a managed care Medicaid model.

Rep. Josh Dobson (R-Nebo) headshot
Rep. Josh Dobson (R-Nebo) Photo courtesy NCGA

North Carolina would also likely need a waiver to add work requirements for the “traditional” Medicaid population, on top of the conversion waiver application that’s already been filed.

“I think it’s too complex to interject into the budget,” he said.

It’s not just complex, it’s also controversial, said Salo. He noted at least a dozen states have asked the federal government for permission to add work requirements to their state Medicaid programs to date, with a handful more contemplating it. But only four states have gotten approval to add the requirements, and the approval was only for adding work in Medicaid expansion states.

Salo speculated that even if CMS officials think that adding work requirements is appropriate for the expansion population, they’re likely “not convinced it can be done appropriately for the traditional Medicaid population.”

That’s because approving such a policy doesn’t guarantee success.

“What I think is going on is that they [at CMS] know, and they’re right, that work requirements and lifetime limits and drug testing and especially work requirements for, you know, single moms making 20 percent of the poverty level, these are all going to get court challenges,” he said. “I think the administration is rightfully thinking it doesn’t do anybody any good if we approve something and we immediately lose in court.”

Hard choices

Meanwhile, advocates in North Carolina have been working the phones and writing letters. A dozen advocacy groups signed onto a letter drafted by NC Child that pointed out there would be a slew of other consequences to work requirements for traditional Medicaid.

NC Child head Michelle Hughes worried about what would happen in very low-income families that qualify for Medicaid because they have young children.

“If they are required to work, they have a hard choice, because many of them don’t have access to affordable child care so it will be challenging for them to work,” she said. “And if they do, their incomes might rise enough that they might not be eligible for Medicaid, but they won’t earn enough to pay for insurance.”

And Corye Dunn from Disability Rights North Carolina pointed out that the state has one of the country’s longest waits for Social Security Disability benefits. She said that there would likely be people who are legitimately disabled but haven’t gotten an “official” designation yet. Those people might be compelled to look for work despite their health challenges.

“There are a lot of people in the deaf community that do have a hard time finding a job because it’s hard to get hired,” said Greg Blevins, from the NC Association of the Deaf.

“Deaf people can’t talk on the phone, work at a front desk, people could accommodate that but the workplace is afraid to try, so deaf people get stuck in the middle.”

Both Dunn and Blevins noted that people with disabilities face a lot of discrimination when they attempt to enter the marketplace. Someone who isn’t “disabled” enough for Social Security benefits but who is disabled enough to have trouble holding down a job might end up without health care coverage, just when they need it.

“The legislature needs to look at every individual person,” Blevins said.  “They need to do more research before they make a general rule.”

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Rose Hoban

Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...

One reply on “State Budget Writers Contemplate Adding Medicaid Work Requirements”

  1. What about a person with mental disability’s? They come and go and so do the jobs. It’s tough enough to get a job with mental disability like Psychological And SUD to keep. Let alone the transportation and then meeting the guidelines of income on a SSI income of $735.00 a month minus what you have to pay back to SSI when you exceed that amount ! It’s a catch 22. And keeps people in the poverty level as is! I can attest to this with my son .

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