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Breaking controversial new ground, the Centers for Medicare & Medicaid Services (CMS) recently invited states to consider establishing work requirements as a condition of receiving Medicaid benefits. Noncompliant beneficiaries may lose some or all benefits, and if they do, will incur higher spending if they have to pay for medical care out of pocket. Current evidence suggests work requirements and related policies, which proponents claim promote personal responsibility, can create considerable risks of health and financial harm in vulnerable populations. Concerns about implementing these policies in Medicaid have been widely expressed, including by major physician organizations, and others have examined their legality. Setting these issues aside, if the policies survive legal challenges, CMS should act to minimize the potential harms these policies could cause to the health of Medicaid’s vulnerable population. To this end, CMS should create guidance that would minimize risks, ensure proportionality of penalties (i.e., that benefits are not eliminated for first-time or relatively minor infractions), and stipulate when harms rise to a level that requires program changes or termination.


Health law & policy, social insurance, Medicaid, eligibility, work requirements, Section 1115 demonstration projects, waivers, health risks, assessment, transparency

Publication Title

JAMA Viewpoint

Publication Citation

JAMA Viewpoint, May 7, 2018