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Federal Public Comment Opposing Proposed Medicaid Work Requirement Waiver in Ohio
March 25, 2025
We respectfully submit these comments with recommendations for re-evaluation of the Ohio Department of Medicaid’s Group VIII Work Requirement and Community Engagement Section 1115 waiver demonstration submission. The proposed waiver, in its present form, is likely to increase state government costs while diminishing access to health care for hundreds of thousands of Ohioans. Any work requirement waiver must include exemptions that will not hinder economic stability or advancements made in public health.
We respectfully request that decision makers re-evaluate the waiver, considering the recommendations that we have included and work toward a solution that ensures comprehensive and equitable health care for all Ohioans. Extensive evidence from past implementations in Arkansas and Georgia clearly show that work requirement waivers do not achieve their stated goals and, in fact, inflict significant harm on vulnerable low-income populations.
Evidence from Arkansas and Georgia
In Arkansas, when work requirement policies were in effect from June 2018 through March 2019, more than 18,000 Medicaid beneficiaries were disenrolled, despite nearly all affected individuals either already working, attending school, or engaged in caregiving activities.[i],[ii] Research has shown that these policies produced no significant increase in employment and instead resulted in higher uninsured rates, delays in care, and increased medical debt. Similarly, Georgia’s Pathways to Coverage program, which imposed a work requirement, had low enrollment, high administrative costs, and burdensome reporting processes that restricted access to essential health care services.[iii], [iv] Both examples illustrate that adding a work requirement not only fails to promote self-sufficiency but also creates unnecessary barriers that undermine the integrity of Medicaid.
Implications for Ohio
Applying similar work requirements in Ohio would likely have a profoundly negative impact. Ohio’s Medicaid population includes many low-income, working-age adults who already face challenges related to transportation, caregiving responsibilities, and job instability. Imposing more administrative burdens and eligibility conditions would risk unnecessary disenrollment, worsen coverage gaps, and hinder access to prompt care, especially for those already struggling to maintain employment. Rather than encouraging workforce participation, such policies would likely lead to adverse health outcomes and increased financial insecurity among Ohioans, contrary to Medicaid’s core mission of protecting health and economic security for many people with lower incomes.
The proposal, as currently drafted, poses significant risks to some of our most vulnerable residents. Notably, if all at‐risk individuals are denied coverage, Ohio’s working-age uninsured rate would climb from the current rate of 8.8 percent to 15.3 percent, levels not seen since the early 2010s.[v] This potential increase in the uninsured rate not only signals a regression in our state’s public health achievements but also threatens to exacerbate existing socioeconomic disparities.
The waiver is intended to link eligibility to work, however in practice, it is slated to diminish access to necessary health care for many Ohioans. Given that those who are most affected by this waiver are already facing challenges in securing stable employment, the proposed work requirements risk pushing hundreds of thousands of Ohioans further into economic and health insecurity.[vi] There are several changes to the current waiver application that would help to mitigate some adverse effects on vulnerable populations.
Rationale for modification
The current draft of Ohio’s Group VIII Work Requirement and Community Engagement Section 1115 waiver demonstration does not sufficiently consider the diversity of family situations, caregiving responsibilities, or economic fluctuations that can impact a person’s ability to meet work requirements.[vii] It is critical that the Department of Medicaid incorporate more flexible provisions that acknowledge the various types of circumstances faced by working-age Ohioans to avoid negative impacts on health coverage and affordability of health care.[viii] Below are detailed recommendations to revise the waiver in a manner that protects public health, while remaining responsive to economic conditions.
- Expanded exemption for caregivers: The waiver should explicitly exempt adults who serve as caregivers. At Community Solutions, we reviewed data collected by the U.S. Census Bureau between July 26 and August 7, 2023, which indicated that over 234,000 Ohio adults were not working because they were caring for children who are not in school or daycare or for an elderly person.[ix] The proposed exemption should apply to all households containing individuals aged 18 and younger, as well as to households with members aged 55 and over, and those households containing someone with a disability, regardless.
- Economic downturn provisions: The waiver should include provisions that can be activated during periods of economic downturn. Like SNAP’s approach, which waives work requirements in regions with higher unemployment, labor surplus, or in areas affected by declining industries.[x] The waiver should offer flexibility under economic stress. Furthermore, explicit provisions for emergency situations, such as natural disasters, should be incorporated. These measures would ensure that during times of widespread economic disruption, added safeguards are in place to protect those who might otherwise lose access to vital health care services.
- Continuity of care for chronic conditions: Continuity of care is paramount, particularly for individuals managing chronic conditions. Interruptions in care due to work requirement compliance could result in deteriorations in health and increased long-term costs. To ameliorate these negative consequences, the waiver should provide exemptions not only to those who meet criteria for disability status, but also, to individuals living with chronic conditions prior to them meeting criteria of disability. Such an exemption would acknowledge the need for uninterrupted medical treatment and would help prevent exacerbations that lead to more costly emergency interventions.
- Household-level exemptions: In households where any member is enrolled in any Medicaid eligibility category, an exemption should be automatically granted to all members. Enrollment in Medicaid is, in itself, an indication of low income or the presence of a life-limiting disability. By extending the exemption to entire households, the policy would recognize the interconnected nature of family financial and health circumstances, thereby reducing the risk of compounded hardship.[xi]
- Exemptions for vulnerable youth and formerly vulnerable populations: Given contemporary research on the long-term impact of early trauma on development,[xii] the waiver should exempt former foster youth, formerly incarcerated juveniles, and any person who was previously enrolled in Temporary Assistance for Needy Families (TANF) through the child-only category. These groups, by virtue of their past experiences, are particularly susceptible to the negative consequences of interrupted health care and inconsistent support. A tailored exemption would help mitigate the detrimental effects that such disruptions might have on their future well-being.
- Exemptions for those experiencing Houselessness: Individuals experiencing houselessness often do not have a fixed address, reliable transportation, or consistent means of communication.[xiii] These are the necessities for searching for, securing, and documenting employment opportunities. As a result, imposing work requirements on this population can inadvertently lead to the loss of Medicaid coverage, even though these individuals are unable to comply with the stipulations often imposed by Medicaid work requirements, through no fault of their own.[xiv] Those without stable housing are more likely to have chronic health issues, mental health disorders, and substance use challenges. Interrupting or denying their access to health care by enforcing work requirements can worsen these conditions.
Continuous access to Medicaid is critical for managing the aforementioned comorbidities effectively. In fact, research shows that when individuals experiencing houselessness maintain uninterrupted Medicaid coverage, they are more apt to engage with health care that transitions them out of houselessness.[xv] Thus, waiving work requirements for this group is a pragmatic response to their unique challenges and an ethical imperative.
County-Level Analysis and Projected Impacts
At The Center for Community Solutions, we have developed current estimates that suggest that if the proposed waiver is implemented without appropriate exemptions, up to 450,000 Ohioans could be at risk of losing health coverage.[xvi] This number far exceeds the Ohio Department of Medicaid’s estimates that “in CY 2026 no more than 61,826 individuals will be considered not exempt and not currently working.” The actual number of affected Ohioans could be staggering.
Additionally, a recent analysis of county-level data from The Center for Community Solutions illustrates the widespread impact that this waiver will have on counties throughout Ohio. In 2023, Franklin County residents comprised 12.8 percent of Ohio’s total working-age Medicaid expansion population. From calculations completed by Community Solutions, an estimated 7,898 individuals in Franklin County alone could lose coverage. More counties face even greater risks. For instance, Pike County has the highest proportion of at-risk working-age residents at 15.9 percent, with Scioto County following at 15.2 percent. Eleven other counties exceed a threshold of 10 percent of their working-age populations being at risk. Many of these counties are characterized by unemployment rates that exceed the state average, suggesting that employment opportunities are limited, and that the waiver could further strain these local economies.
Statistical evidence underscores the potential for a dramatic increase in the uninsured rate, particularly in rural and economically challenged areas. Eighteen counties, many of which are small and rural, could experience uninsured rates exceeding 20 percent. This surge in the uninsured population would likely result in negative economic repercussions, including reduced productivity, lower wages, and increased employee turnover, all outcomes that would negate the intended benefits of linking Medicaid eligibility to work.
Conclusion and Call to Action
In conclusion, while the intention behind the proposed Medicaid work requirement waiver may be to encourage employment, the actual impact is poised to be counterproductive. The waiver, as currently drafted, does not account for the complexities of individual and household circumstances, particularly in times of economic downturn or during public health emergencies. The potential rise in the uninsured rate, from 8.8 percent to 15.3 percent, represents not only a regression in advances made to better public health but also a profound risk to the well-being of Ohio’s residents.
Based on the compelling evidence from Arkansas and Georgia, we urge federal decision-makers to re-evaluate the work requirement waiver submitted by the Ohio Department of Medicaid. In Ohio and all other states, such waivers threaten to destabilize an already fragile system, resulting in avoidable harm to hundreds of thousands of low-income insureds who are enrolled in Medicaid for access to essential health care.
By introducing targeted exemptions for caregivers, individuals with chronic conditions, vulnerable youth, eligible households, and those experiencing houselessness, the waiver can be restructured to better protect those who are most in need. Moreover, including provisions activated during economic downturns or public health emergencies would ensure the waiver is flexible and humane.
This comment is submitted with the aim that the recommendations will prompt a comprehensive re-examination of the Ohio Department of Medicaid’s work requirement waiver submission, ensuring that any changes allow for the type of continuity of care that ensures both the health and economic stability of all Ohioans.
We respectfully request that the Centers for Medicare & Medicaid Services maintain Medicaid’s proven, inclusive eligibility criteria and focus on policies that strengthen coverage without imposing counterproductive barriers.
Sources
[i] Chen L, Sommers BD. “Work Requirements and Medicaid Disenrollment in Arkansas, Kentucky, Louisiana, and Texas, 2018.” Am J Public Health. 2020 Aug;110(8):1208-1210. doi: 10.2105/AJPH.2020.305697. Epub 2020 Jun 18. PMID: 32552024.
[ii] https://www.kff.org/medicaid/issue-brief/5-key-facts-about-medicaid-work-requirements/#:~:text=More%20than%2018%2C000%20people%20lost%20coverage%2C%20or%20about,work%20status%20or%20document%20eligibility%20for%20an%20exemption.
[iii] Musumeci, MaryBeth, Elizabeth Leiser and Megan Douglas, “Few Georgians are Enrolled in the State’s Medicaid Work Requirement Program” Commonwealth Fund, 11 September 2024.
[iv] https://www.kff.org/medicaid/issue-brief/5-key-facts-about-medicaid-work-requirements/#:~:text=More%20than%2018%2C000%20people%20lost%20coverage%2C%20or%20about,work%20status%20or%20document%20eligibility%20for%20an%20exemption.
[v] Campbell, Emily, “Ohio’s proposed Medicaid work requirement could cost thousands of Ohioans their healthcare coverage.” The Center for Community Solutions, 13 January 2025. https://www.communitysolutions.com/resources/ohio-medicaid-work-requirement-lose-healthcare-coverage.
[vi] Gilkesson, Parker and Teon Hayes, “Work requirements won’t lead to better employment or economic outcomes” The Center for Law and Social Policy, 15 March 2023. https://www.clasp.org/blog/work-requirements-wont-lead-to-better-employment-or-economic-outcomes/.
[vii] Donelson, Rolonda and Madeline Morcelle, “Protect Medicaid Funding Issue #13: Medicaid Work Requirements Hurt the U.S. Workforce” National Health Law Program, September 2024.
[viii] Sommers, Benjamin et al., “Medicaid Work Requirements in Arkansas: Two-Year Impacts on Coverage, Employment, and Affordability of Care.” Health Affairs, September 2020.
[ix] Campbell, Emily, “Record Low Unemployment Statistics Leave Out Millions of Ohioans,” https://www.communitysolutions.com/resources/record-low-unemployment-statistics-leave-out-millions-of-ohioans.
[x] USDA Food and Nutrition Service, “Guide to Supporting Requests to Waive the Time Limit for Able-Bodied Adults without Dependents (ABAWD),” 21 September 2021. https://www.fns.usda.gov/snap/guide-supporting-requests-waive-time-limit-abawd.
[xi] DeVoe JE, Krois L, Edlund T, Smith J, Carlson NE. “Uninsurance among children whose parents are losing Medicaid coverage: Results from a statewide survey of Oregon families.” Health Serv Res. 2008 Feb;43(1 Pt 2):401-18. doi: 10.1111/j.1475-6773.2007.00764.x. PMID: 18199193.
[xii] Booshehri LG, Dugan J, Patel F, Bloom S, Chilton M. Trauma-informed Temporary Assistance for Needy Families (TANF): A Randomized Controlled Trial with a Two-Generation Impact. J Child Fam Stud. 2018;27(5):1594-1604. doi: 10.1007/s10826-017-0987-y. Epub 2018 Jan 1. PMID: 29657515; PMCID: PMC5886995.
[xiii] Medicaid Work Requirements for Enrollees | Commonwealth Fund
[xiv] Medicaid Work Requirements Could Put 36 Million People at Risk of Losing Health Coverage | Center on Budget and Policy Priorities
[xv] Willison CE, Lillvis D, Mauri A, Singer PM. Technically Accessible, Practically Ineligible: The Effects of Medicaid Expansion Implementation on Chronic Homelessness. J Health Polit Policy Law. 2021 Dec 1;46(6):1019-1052. doi: 10.1215/03616878-9349142. PMID: 34075407; PMCID: PMC9648193.
[xvi] Campbell, Emily, “Ohio’s proposed Medicaid work requirement could cost thousands of Ohioans their healthcare coverage.” The Center for Community Solutions, 13 January 2025. https://www.communitysolutions.com/resources/ohio-medicaid-work-requirement-lose-healthcare-coverage.
