They’re at it again, unfortunately. Today, the Trump Administration and newly-confirmed Secretary of Health and Human Services (HHS) Alex Azar renewed the Healthy Indiana Plan (HIP) 2.0 Section 1115 waiver, including a work requirement on the Medicaid expansion population. Indiana now joins Kentucky as the second state to add a work requirement to its Medicaid program. This is likely the beginning of a regrettable trend, as almost 10 other states have submitted waiver applications seeking work requirements and several others are considering legislation.

Work requirements are unnecessary and harmful to coverage and care

Indiana wants all “able-bodied” adults between ages 19-64 to now prove they are working or participating in work-like activities for a certain amount of hours per week, based on the length of time they’re enrolled in Medicaid. If HIP 2.0 enrollees are either not engaging in these activities for fail to submit the right amount or type of paperwork to prove they are working, their coverage will be suspended until they work or participate in work-like activities for one month.

Work requirements are unnecessary and harmful to individuals because they have been shown to be ineffective at helping individuals find or maintain employment. In addition, most Medicaid enrollees who can work, do so, and therefore work requirements won’t help these individuals find or keep a job, but rather will only serve as an unnecessary administrative requirement. Not to mention that individuals who are healthy are better able to work, so allowing these individuals to stay enrolled in Medicaid would be a more effective way for a state to support employment.

While the HIP 2.0 plan provides exemptions to certain individuals, such as students, parents and individuals “participating in substance use disorder [SUD] treatment activities,” there are notable populations who are not exempt, such as individuals with SUD who are not yet in treatment. Work requirements are particularly troubling for individuals with SUD because access to consistent treatment is important for these populations. Rewarding only those in “active” treatment may exclude those who have completed treatment but are still receiving services from community-based recovery programs.

Moreover, providing exemptions to various vulnerable populations does not protect them from losing coverage. Rather, exempt individuals are equally at risk of losing coverage as those who must prove they’re working because they’re similarly subjected to paperwork requirements. The real danger of work requirements, therefore, is that they require all Medicaid enrollees, including those who are working and eligible for an exemption – to meet specific paperwork amounts, types and submission deadlines, or lose coverage if they don’t.

Work requirements will add complexity and cost to an already complex and costly program

The HIP 2.0 work requirements will only add to a series of complex administrative requirements enrollees must already meet, including paying premiums before enrollment can begin (and being locked out for failing to pay premiums), complying with healthy behavior incentives and participating in a high-deductible health plan with a health savings account. Recent evaluations found these policies to be confusing for enrollees and burdensome and costly for providers. Despite these recent findings, HHS has renewed all of these provisions through 2023. It’s troubling that, in addition to all of the complexity already found in HIP 2.0, work requirements will now be added to the mix.

Fortunately, advocacy groups are taking action and recently filed litigation in Kentucky against work requirements. While the litigation is ongoing, it’s important for advocates in states that may be contemplating a work requirement to begin the process of preventing them now, by educating the communities they serve, stakeholders, and policymakers about the dangers of work requirements so that what’s happened in Indiana and Kentucky will not happen in their state.