IWPR Comments Regarding State Implementation of Medicaid Work Requirements

Submitted July 31, 2026 via regulations.gov.

Re: Medicaid Program; Community Engagement Requirement for Certain Individuals (CMS-2454-IFC)

On behalf of the Institute for Women’s Policy Research (IWPR), thank you for the opportunity to provide comments on the Centers for Medicare & Medicaid Services (CMS) interim final rule CMS-2454-IFC, establishing nationwide requirements to guide state implementation of Medicaid work requirements.

IWPR is a nonpartisan, nonprofit organization that conducts and disseminates research to shape policies that close inequality gaps and improve the economic well-being of women and families from diverse backgrounds. As part of our efforts to support women’s economic security and well-being, we focus on understanding the economic impacts of disparities in access to and restrictions on health care. As a leading national think tank that routinely employs the highest standards of integrity and quality in our research, IWPR is uniquely positioned to comment on the harmful impacts that the interim final rule’s framework for Medicaid eligibility and work requirement verification and enforcement will have on the economic security and well-being of women and their families—particularly women of color and those living with a disability.

IWPR strongly opposes the interim final rule and urges CMS to take every action to ensure people are not forced to lose Medicaid coverage for critical health care services due to unnecessary and burdensome requirements.

Following the passage of H.R. 1, known as the “One Big Beautiful Bill Act” (OBBB), the interim final rule seeks to implement work requirements for Medicaid recipients in 41 states that expanded Medicaid for adults in the Affordable Care Act (ACA), as well as enrollees in certain waiver programs, including in non-expansion states. In its proposed rule, the agency goes beyond the underlying law’s requirement with even further arbitrary and burdensome “medical frailty” exemption requirements. These barriers to Medicaid eligibility reverse progress made in health insurance coverage in the US since the implementation of the ACA and are founded on faulty premises, disproven by abundant research on the ineffectiveness of work requirements.

Research Shows Work Requirements Are Punitive and Inefficient

Contrary to the purported premise that work requirements incentivize employment among low-income individuals, research has consistently demonstrated that the implementation of work requirements is costly, causes eligible individuals to lose benefits, and harms the potential for upward economic mobility for families. Research published in the New England Journal of Medicine found that Arkansas’s work requirement for Medicaid led to significant decreases in coverage, with no measurable improvement in employment.¹ These losses are due to burdensome red tape to prove “community engagement” or 80 hours of employment within the last month and new requirements to prove medical frailty. As a result of prior work requirements, eligible individuals often fall through the cracks when states do not automatically identify exemptions and state agencies take on the onerous task of managing new definitions and systems to operationalize the rule. Based on coverage loss rates experienced in Arkansas under its ill-fated work requirement implementation from 2018–2019, the Center for Budget and Policy Priorities estimates more than seven million people are at risk of losing coverage.² The Urban Institute’s Health Insurance Policy Simulation Model finds similar levels of coverage loss.³

Furthermore, expanding work requirements is counterproductive to helping individuals on a path of upward economic mobility. Research by Georgetown University economists found that the expansion of Medicaid eligibility income thresholds resulted in recipients being better able to transition into higher-paying jobs.⁴ Research from Boston College’s Center for Retirement Research finds that expanding health insurance coverage through Medicaid expansion leads to a healthier and more productive workforce.⁵ Additional research on work requirements for social programs more broadly finds that there may only be modest improvements in employment outcomes, which are more likely when paired with work supports.⁶ Opposition to social programs is often informed by racist biases and stereotypes of welfare recipients,⁷ rather than evidence that they are disincentives to work.

Dismantling a Decade of Progress in Increasing Access to Health Care Coverage and Services

Implementation of the draconian interim final rule would unravel a decade of progress in increasing access to health care. With millions at risk of losing their health insurance, women, who are a majority of Medicaid recipients, as well as Black, Latino, and Indigenous communities, who are also more likely to face difficulty in accessing care due to racialized systemic disparities, face disproportionate harm.⁸ The United States has a persistent and troubling Black maternal health crisis, which will only be worsened by creating more red tape for eligible pregnant people. Though individuals who are pregnant or postpartum are exempt from the OBBB’s Medicaid work requirements, evidence shows the importance of prepregnancy health and access to high-quality care for maternal health.⁹

Despite the exemption, the implementation of the interim final rule and the resulting loss of coverage for millions undermine the progress of Medicaid expansion, which research shows has contributed to improved health among pregnant women, not only related to the birth of a child but also to their overall health outcomes.¹⁰ Communities already experiencing health disparities and the most marginalized will be harmed the most.

Harmful Nationwide Economic Consequences

Reducing access to health insurance has spillover effects for the wider economy. The health care sector has driven employment growth in recent years.¹¹ The Commonwealth Fund estimates that coverage loss from changes made by the OBBB would lead to half a million jobs lost in health care.¹² The same analysis finds that states would lose a total of $95.7 billion in Medicaid funding, with states losing as much as 21.1 percent of their federal Medicaid funding. The loss of Medicaid reimbursements could lead to the closure of health care facilities, impacting all people who rely on those facilities and further harming the health care sector.

Beyond the negative impacts on the health care sector, the consequences of a lack of health insurance are also bad for the economy. In a meta-analysis that surveys all relevant literature, researchers found that health insurance—and in particular public health insurance—promotes better economic performance in advanced economies.¹³ Healthy people are more likely to invest in their human capital through education and training, have fewer absences from work and longer working lives, and support productivity growth. Dismantling progress made by the ACA in expanding coverage will also send the economy backward.

Knocking Over an Unstable Economy

The economy is currently on an unstable trajectory. The labor market is adding jobs at a slowing pace. Inflation is persistent and elevated due to high energy costs, leading to negative wage growth for workers. This is in addition to the long-run increase in costs for critical services like health care, child care, and housing.¹⁴ Research has shown that accessible basic services like health care are a necessary foundation for growth, rather than a disincentive to work and fully engage in the economy. Taking away coverage from individuals and funding from states as the economy slows down imposes unnecessary risks to economic stability.

Conclusion

The evidence is clear that work requirements, regardless of whether framed as “community engagement” or not, do more harm than good. The interim final rule imposes onerous barriers for Medicaid recipients that will lead to eligible people losing health insurance, requires states to implement new processes and systems that will lead to inefficiencies, and results in lower overall funding for health care when coverage is as critical as ever. Reduced funding will lead to job losses in health care, the most critical sector of the labor market for job growth. The reasoning behind implementing draconian work requirements is to incentivize work, while evidence suggests the opposite will happen. Accessible Medicaid has been shown to help people match into better jobs and be more productive members of the economy.

IWPR therefore strongly opposes the interim final rule and urges the Centers for Medicare & Medicaid Services to instead make every possible effort to ensure that Americans do not lose the health insurance coverage that is the foundation of individual health and economic security. Implementation of this rule will cause harm to individuals, families, states, and the national economy, with little discernible benefit.

Thank you again for the opportunity to comment. IWPR remains committed to supporting evidence-informed policies that advance the economic stability, health, and well-being of women and families. Medicaid expansion has played a vital role in this progress, but is threatened by the interim final rule and the underlying OBBB law.

Sincerely,

Kate Bahn, PhD
Chief Economist and Senior Vice President of Research
Institute for Women’s Policy Research

cc: Chris Klomp, Deputy Administrator and Director, Center for Medicaid and CHIP Services, CMS