Mandating work, commanding health, and managing risk: the (bio)politics of Medicaid reform

ABSTRACT

In this article, I analyze proposed Medicaid work requirements to argue that gendered and racialized discourses of poverty and ableist constructs of employability present “able-bodied” Medicaid recipients as a financial and health risk. Focusing on the co-constitution of rhetoric and policy, I trace the ways in which imaginaries of dependency and irresponsibility contribute to the construction and behavioral regulation of the unproductive and unfit bio-Other. I contend that the regulatory machinations of workfare and healthfare compound structural inequities in the labor market, diminish government-funded healthcare provision, and enhance biometric surveillance of Medicaid recipients.

KEYWORDS:

• Biocitizenship
• surveillance; workfare; health imperative

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 Brian Neale, “RE: Opportunities to promote work and community engagement among Medicaid beneficiaries: Letter to State Medicaid Directors on behalf of the Department of Health & Human Services,” Centers for Medicare and Medicaid Services (January 11, 2018): 1–10; Personal Responsibility and Work Opportunity Reconciliation Act (1996), P.L. 104–93, 1.

2 Kaiser Family Foundation, “Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State,” May 3, 2022, https://www.kff.org/report-section/section-1115-waiver-tracker-work-requirements/

3 MaryBeth Musumeci, “Medicaid and Work Requirements,” Kaiser Family Foundation, March 2017, https://files.kff.org/attachment/Issue-Brief-Medicaid-and-Work-Requirements; Kaiser Family Foundation, “Medicaid Waiver Tracker.” While the first work-related waiver requests were made in 2014, and some states maintained voluntary job training and referral programs, CMS did not approve any state work requirements until the Trump administration.

4 Social Security Act Amendments (1965), P.L. 89–7, § 1901.

5 Calder Lynch to Nathan Checketts, Director, Utah Division of Medicaid and Health Financing Department of Health, December 23, 2019, 3; Seema Verma to Casey Himebauch, Deputy Medicaid Director Wisconsin Department of Health Services, October 31, 2018, 3.

6 Madeleine Guth and MaryBeth Musumeci, “An Overview of Medicaid Work Requirements: What Happened Under the Trump and Biden Administrations?,” Kaiser Family Foundation, May 3, 2022, https://www.kff.org/medicaid/issue-brief/an-overview-of-medicaid-work-requirements-what-happened-under-the-trump-and-biden-administrations/; Nancy Fraser and Linda Gordon, “A Genealogy of Dependency: Tracing a Keyword of the U.S. Welfare State,” Signs 19 (1994): 309–36. Divergent views about whether Medicaid constitutes public assistance, health insurance, or both may either account for or provide evidence of the increasingly polarized approaches to Medicaid eligibility conditions. Regardless of Medicaid’s classification, however, recent rhetorical and policy maneuvers that have the potential to bring the program into greater alignment with cash and food assistance programs deserve attention.

7 As I will discuss further, “able-bodied” is a legally and politically meaningful but fraught and misleading category that signifies the absence of a government-recognized disability. Eva Bertram, The Workfare State: Public Assistance Politics from the New Deal to the New Democrats (Philadelphia: University of Pennsylvania Press, 2015), 49.

8 Adele E. Clarke et al., “Biomedicalization: Technoscientific Transformations of Health, Illness, and U.S. Biomedicine,” American Sociological Review 68, no. 2 (2003): 171–2; Michel Foucault, “The Politics of Health in the Eighteenth Century,” in The Foucault Reader, ed. Paul Rabinow (New York: Pantheon Books, 1984), 277; Deborah Lupton, The Imperative of Health: Public Health and the Regulated Body (New York: Sage, 1995); Jonathan M. Metzl, “Introduction: Why ‘Against Health’?,” in Against Health: How Health Became the New Morality, ed. Jonathan M. Metzl and Anna Kirkland (New York: New York University Press, 2010), 6, 9; Geneviève Rail and Shannon Jette, “Reflections on Biopedagogies and/of Public Health: On Bio-Others, Rescue Missions, and Social Justice,” Cultural Studies ↔ Critical Methodologies 15, no. 5 (2015): 328.

9 Robert Asen, “Reflections on the Role of Rhetoric in Public Policy,” Rhetoric & Public Affairs 13, no. 1 (2010): 121–43.

10 Asen, “Reflections on the Role of Rhetoric,” 127; Robin E. Jensen, The Sage Handbook of Risk Communication (Thousand Oaks, CA: SAGE Publications, Inc., 2014), 2–3, 5–6; Rozier and Singer, “The Good and Evil of Health Policy: Medicaid Expansion, Republican Governors, and Moral Intuitions,” AJOB Empirical Bioethics 12, no. 3 (2021): 146.

11 Asen, Visions of Poverty, 7, 15.

12 Fraser and Gordon, “A Genealogy of Dependency,” 309–36; Anna Marie Smith, “The Politicization of Marriage in Contemporary American Public Policy: The Defense of Marriage Act and the Personal Responsibility Act,” Citizenship Studies 5, no. 3 (2001): 303–20; Joe Soss, Richard C. Fording, and Sanford Schram, Disciplining the Poor: Neoliberal Paternalism and the Persistent Power of Race (Chicago: University of Chicago Press, 2011); Loic Wacquant, Punishing the Poor: The Neoliberal Government of Social Insecurity (Durham, NC: Duke University Press, 2009).

13 Stephen H. Bell and L. Jerome Gallagher, “Prime-Age Adults Without Children or Disabilities: The Least-Deserving of the Poor – or Are They?,” The Urban Institute (February 2001): 1.

14 Karen D’Angelo, Kathryn Libal, Nicole Seymour, and Renee Hamel, “After the ‘Great Recession’: Excluding ‘Able-Bodied’ Adults from Food Entitlements in the United States,” Journal of Policy Practice 16, no. 4 (2017): 453–5; Megan Welsh, “Categories of Exclusion: The Transformation of Formerly Incarcerated Women into Able-Bodied Adults Without Dependents in Welfare Processing,” Journal of Sociology & Social Welfare 42 (2015): 55–77. Able-bodied Adults Without Dependents (ABAWDs) are not eligible for federal cash assistance and may only receive food assistance for three months out of every three years, unless they engage in 20 h per week of approved work activities. Although Medicaid work requirements would apply to “able-bodied” beneficiaries with and without dependents, depending on the state, the expansion adult population is often conflated with the ABAWD category and therefore imagined as nonparents.

15 Miranda Joseph, “Gender, Entrepreneurial Subjectivity, and Pathologies of Personal Finance,” Social Politics 20, no. 2 (2013): 252–9; Joseph, Debt to Society, xiv.

16 Anna M. Smith, Welfare Reform and Sexual Regulation (New York: Cambridge University Press, 2007); Soss, Fording, and Schram, Disciplining the Poor.

17 Claudia Aradau, “The Perverse Politics of Four-Letter Words: Risk and Pity in the Securitization of Human Trafficking,” Millennium 33, no. 2 (2004): 251–77; Miranda Joseph, Debt to Society: Accounting for Life Under Capitalism (Minneapolis: University of Minnesota Press, 2014), xi, 92; Virginia Eubanks, Automating Inequality: How High-Tech Tools Profile, Police, and Punish the Poor (New York: St. Martin’s Press, 2017), 81.

18 Smith, “The Politicization of Marriage in Contemporary American Public Policy,” 303–20.

19 Khiara M. Bridges, “Pregnancy, Medicaid, State Regulation, and the Production of Unruly Bodies,” Northwestern Journal of Law & Social Policy. 3 (2018): 62–102; Shelley Bielefeld, Jenna Harb, and Kathryn Henne, “Financialization and Welfare Surveillance: Regulating the Poor in Technological Times,” Surveillance & Society 19, no. 3 (2021): 300, 309; Virginia Eubanks, “Technologies of Citizenship: Surveillance and Political Learning in the Welfare System,” in Surveillance and Security: Technological Politics and Power in Everyday Life, ed. Torin Monahan (London: Routledge, 2006), 89–107.

20 Michel Foucault, The History of Sexuality: An Introduction (New York: Vintage Books, 1978/1990), 138; Jenell Johnson, Kelly E. Happe, and Marina Levina, eds., Biocitizenship: The Politics of Bodies, Governance, and Power (New York: New York University Press, 2018), 8; Rail and Jette, “Reflections on Biopedagogies,” 328–9.

21 Clarke et al., “Biomedicalization: Technoscientific Transformations,” 171.

22 Lupton, The Imperative of Health, 77–8; Rail and Jette, “Reflections on Biopedagogies,” 330.

23 Rail and Jette, “Reflections on Biopedagogies,” 330–1.

24 Rail and Jette, “Reflections on Biopedagogies,” 330–1.

25 Rail and Jette, “Reflections on Biopedagogies,” 330–2; Clarke et al., “Biomedicalization: Technoscientific Transformations,” 172–3.

26 In this analysis, I focus on a cross-section of the state proposals for Medicaid work requirements – two that were approved and implemented (Indiana, Utah), two that were approved and not implemented (Arizona, Wisconsin), and two that were set aside by courts (Kentucky, Michigan). Five of the six state proposals also include a monthly premium and/or healthy behavior incentives, which is representative of the larger set of demonstration waivers.

27 Personal Responsibility and Work Opportunity Reconciliation Act (1996), P.L. 104–93.

28 Calder Lynch to State Medicaid Directors, “RE: Healthy Adult Opportunity,” Department of Health & Human Services, Centers for Medicare and Medicaid Services, January 30, 2020; Robin Rudowitz et al., “Implications of CMS’s New “Healthy Adult Opportunity” Demonstrations for Medicaid,” Kaiser Family Foundation, February 5, 2020, https://www.kff.org/medicaid/issue-brief/implications-of-cmss-new-healthy-adult-opportunity-demonstrations-for-medicaid/

29 Medicaid.gov, “Medicaid, Children’s Health Insurance Program, & Basic Health Program Eligibility Levels,” https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-childrens-health-insurance-program-basic-health-program-eligibility-levels/index.html

30 Affordable Care Act (2010), P.L. 111–48.

31 Kaiser Family Foundation, “Status of State Medicaid Expansion Decisions: Interactive Map,” https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/. Demonstration waivers must be approved by the Secretary of the Department of Health and Human Services in accordance with Section 1115(a)(2) of the amended Social Security Act (1965).

32 Social Security Act Amendments (1965) P.L. 89–7, 42 U.S.C. § 1315. ACA-led Medicaid expansion was not the only mechanism for the restriction of benefits and behavioral conditions, as several states pursued work requirements independent of eligibility expansion. Prior to the Trump administration, no state waiver requests to condition eligibility on work activities had been approved.

33 Social Security Act (1935), P.L. 74-271; Bertram, The Workfare State, 49.

34 Fraser and Gordon, “A Genealogy of Dependency,” 322–3; Welsh, “Categories of Exclusion,” 58.

35 Bertram, The Workfare State, 49.

36 Eubanks, “Automating Inequality,” 28–9.

37 Mimi Abramovitz, Regulating the Lives of Women: Social Welfare Policy from Colonial Times to the Present (Boston: South End Press, 1996, 2nd ed.); Linda Gordon, Pitied but Not Entitled: Single Mothers and the History of Welfare, 1890–1935 (New York: Free Press, 1994); Eubanks, Automating Inequality, 27–30.

38 Nancy Fraser, “Women, Welfare, and the Politics of Need Interpretation,” Hypatia 2, no. 1 (1987): 103–21.

39 Bertram, The Workfare State, 28–96.

40 Bertram, The Workfare State, 76–85.

41 Bertram, The Workfare State, 85–92.

42 Bertram, The Workfare State, 153; Fraser and Gordon, “A Genealogy of Dependency,” 327.

43 Scott Szymendera, “Primer on Disability Benefits: Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI),” Congressional Research Service (February 2, 2010): 3.

44 Szymendera, “Primer on Disability Benefits,” 7; Paul K. Longmore, “Why I Burned My Book,” in Why I Burned My Book and Other Essays on Disability (Philadelphia: Temple University Press), 245.

45 Fraser and Gordon, “A Genealogy of Dependency,” 327–9.

46 Mimi Abramovitz, Regulating the Lives of Women; Linda Gordon, Pitied but Not Entitled; Eubanks, Automating Inequality, 27–30.

47 David Machledt, “‘Unfit’ to Work? How Medicaid Work Requirements Hurt People with Disabilities,” National Health Law Program (May 2023): 4; Ed Bolen, Dottie Rosenbaum, and Catlin Nchako, “Families, Older People in Every State at Risk Under Proposed SNAP Rule That Would Take Food Away for Not Meeting Work Requirements,” Center on Budget and Policy Priorities, March 28, 2023, 1.

48 Eubanks, “Automating Inequality,” 28.

49 Longmore, “Why I Burned My Book,” 243–5.

50 Longmore, “Why I Burned My Book,” 245; Szymendera, “Primer on Disability Benefits,” 5.

51 Longmore, “Why I Burned My Book,” 238–40.

52 Bertram, The Workfare State, 153; Frances Fox Piven and Richard Andrew Cloward, Regulating the Poor: The Functions of Social Welfare (New York: Vintage, 1971); Smith, Welfare Reform and Sexual Regulation; Nikolas Rose, Powers of Freedom: Reframing Political Thought (New York: Cambridge University Press, 1999).

53 Eubanks, Automating Inequality, 33–8; U.S. Department of Agriculture, “EBT: Electronic Benefits Transfer (EBT) Status Report by State,” September 5, 2017.

54 Bielefeld et al., “Financialization and Welfare Surveillance,” 300, 306.

55 Rachel E. Dubrofsky and Shoshana A. Magnet, “Introduction: Feminist Surveillance Studies: Critical Interventions,” in Feminist Surveillance Studies, ed. Rachel E. Dubrofsky and Shoshana A. Magnet (Durham: Duke University Press, 2015), 1–2; Torin Monahan, “Regulating Belonging: Surveillance, Inequality, and the Cultural Production of Abjection,” Journal of Cultural Economy 10, no. 2 (2017): 191, 201; Torin Monahan, “Dreams of Control at a Distance: Gender, Surveillance, and Social Control,” Cultural Studies ↔ Critical Methodologies 9, no. 2 (2009): 286–305; Christa Teston, “Rhetoric, Precarity, and mHealth Technologies,” Rhetoric Society Quarterly 46, no. 3 (2016): 255, 266.

56 Bielefeld et al., “Financialization and Welfare Surveillance,” 300, 306; Monahan, “Regulating Belonging,” 192–3, 198.

57 American Health Care Act (2017), H.R. 1628.

58 American Health Care Act (2017), H.R. 1628.

59 Thomas E. Price and Seema Verma to governors, The Secretary of Health and Human Services, March 14, 2017, 1–3.

60 Neale, “RE: Opportunities to Promote Work and Community Engagement among Medicaid Beneficiaries,” 1–10; Personal Responsibility and Work Opportunity Reconciliation Act (1996) P.L. 104–93.

61 Calder Lynch to State Medicaid Directors, “RE: Healthy Adult Opportunity,” Department of Health & Human Services, Centers for Medicare and Medicaid Services, January 30, 2020; Although participation is voluntary, such a proposal bypasses Congress in converting Medicaid from an entitlement to a conditional benefit. The Trump administration’s FY 2020 budget called for a nationwide Medicaid work mandate for non-disabled beneficiaries.

62 Neale, “RE: Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries,” 1–10; Personal Responsibility and Work Opportunity Reconciliation Act (1996) P.L. 104–93.

63 Gangopadhyaya et al., “Medicaid Work Requirements in Arkansas,” 6; Heather Hahn et al., “Work Requirements in Social Safety Net Programs: A Status Report of Work Requirements in TANF, SNAP, Housing Assistance, and Medicaid,” Urban Institute, December 2017, 17; Kaiser Family Foundation, “Medicaid Waiver Tracker”

64 Hahn et al., “Work Requirements in Social Safety Net Programs,” 17.

65 State of Utah Department of Health, “Utah 1115 Demonstration Waiver Amendment,” November 1, 2019, 3

66 State of Indiana Family and Social Services Administration, “Amendment Request to Healthy Indiana Plan (HIP) Section 1115 Waiver Extension Application,” July 20, 2017, 5.

67 State of Michigan Department of Health and Human Services, “Section 1115 Demonstration Extension Application, Healthy Michigan Plan,” 5.

68 Demetrios L. Kouzoukas to Stephen P. Miller, Commissioner, Kentucky Cabinet for Health and Family Services, January 12, 2018, 3; A district court subsequently vacated the approval of Kentucky HEALTH on the ground that the state “never adequately considered whether Kentucky HEALTH would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid.” Stewart v. Azar, 3l3 F. Supp. 3d 237, 243 (D.D.C. 2018). After remand to CMS, which made minimal changes and re-approved the plan, the district court once again blocked the work requirements in March 2019.

69 Lynch to Checketts, 8.

70 State of Michigan Department of Health and Human Services, “Section 1115 Demonstration Extension Application, Healthy Michigan Plan,” December 6, 2017 (amended 10 September, 2018), 5.

71 State of Michigan Department of Health and Human Services, “Section 1115 Demonstration Extension Application, Healthy Michigan Plan,” 22–3.

72 State of Michigan Department of Health and Human Services, “Section 1115 Demonstration,” 5.

73 Bennett, “Resisting the Rhetoric of Indexing,” 4–5; Crear-Perry et al., “Social and Structural Determinants of Health,” 230–1.

74 Demetrios L. Kouzoukas to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration, February 1, 2018, 6.

75 D’Angelo et al., “Excluding ‘Able-Bodied’ Adults,” 455; Verma to Stiffler, 9, 12; Paul Mango to Carol H. Steckel, “Commissioner, Department for Medicaid Services Commonwealth of Kentucky,” Department of Health and Human Services: Centers for Medicare & Medicaid Services (November 20, 2018): 9, 13; Rozier and Singer, “The Good and Evil of Health Policy,” 148.

76 Price and Verma to governors, 1–3.

77 Kaiser Family Foundation, “Medicaid Waiver Tracker”

78 Lynch to Checketts, 8.

79 Nic Horton and Jonathan Ingram, “The Future of Medicaid Reform: Empowering Individuals Through Work,” Foundation for Government Accountability (November 14, 2017): 6, 9.

80 Bridges, “Pregnancy, Medicaid, State Regulation, and the Production of Unruly Bodies,” 62–102.

81 Centers for Medicare and Medicaid Services, “About Section 1115 Demonstrations,,” https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations/index.html.

82 Seema Verma to Kathy Stiffler, Acting Director State of Michigan, Department of Health and Human Services, December 21, 2018, 12; State of Michigan Department of Health and Human Services, “Section 1115 Demonstration Extension Application, Healthy Michigan Plan,” 5.

83 Asen, “Reflections on the Role of Rhetoric,” 127.

84 Demetrios L. Kouzoukas to Allison Taylor, Medicaid Director, Indiana Family and Social Services Administration, February 1, 2018, 6; Lynch to Checketts, 9; Mango to Steckel, 9; Verma to Himebauch, 6, 8; State of Utah Department of Health, “Utah 1115 Demonstration Waiver Amendment,” November 1, 2019, 3.

85 Bolen et al., “Families, Older People,” 1; Benjamin D. Sommers et al., “Medicaid Work Requirements: Results from the First Year in Arkansas,” New England Journal of Medicine 381, no. 11 (2019):1073–82.

86 Hahn et al., “Work Requirements in Social Safety Net Programs,” 1–46; Erin Brantley, Drishti Pillai, and Leighton Ku, “Association of Work Requirements with Supplemental Nutrition Assistance Program Participation by Race/Ethnicity and Disability Status, 2013–2017,” JAMA Network Open 3, no. 6 (2020): 7–8.

87 Bolen et al., “Families, Older People,” 3–4; Guth and Musumeci, “An Overview of Medicaid Work Requirements”; Machledt, “‘Unfit’ to Work,” 2.

88 Garfield et al., “Implications of a Medicaid Work Requirement: National Estimates of Potential Coverage Losses,” Kaiser Family Foundation, June 27, 2018, https://www.kff.org/medicaid/issue-brief/implications-of-a-medicaid-work-requirement-national-estimates-of-potential-coverage-losses/; Rudowitz et al., “February State Data for Medicaid Work Requirements in Arkansas,” Kaiser Family Foundation, Mar 25, 2019, https://www.kff.org/medicaid/issue-brief/state-data-for-medicaid-work-requirements-in-arkansas/

89 Anuj Gangopadhyaya et al., “Medicaid Work Requirements in Arkansas: Who Could Be Affected, and What Do We Know About Them?” Urban Institute, May 2018, 1–34; Rachel Garfield, Robin Rudowitz, and MaryBeth Musumeci, “Implications of a Medicaid Work Requirement: National Estimates of Potential Coverage Losses,” 5.

90 Machledt, “‘Unfit’ to Work,” 3.

91 Guth and Musumeci, “An Overview of Medicaid Work Requirements.”

92 Brantley et al., “Association of Work Requirements,” 8; Center on Budget and Policy Priorities, “Taking Away Medicaid for Not Meeting Work Requirements Harms People with Disabilities,” March 10, 2020, https://www.cbpp.org/research/health/taking-away-medicaid-for-not-meeting-work-requirements-harms-people-with; Machledt, “‘Unfit’ to Work,” 3–5.

93 Bolen et al., “Families, Older People,” 6.

94 Longmore, “Why I Burned My Book,” 243–5.

95 Price and Verma to governors, 2.

96 Machledt, “‘Unfit’ to Work,” 2.

97 Asen, Visions of Poverty, 7.

98 Clarke et al., “Biomedicalization: Technoscientific Transformations,” 171–2.

99 Clarke et al., “Biomedicalization: Technoscientific Transformations,” 170, 172, 184; Rail and Jette, “Reflections on Biopedagogies,” 328–9.

100 Mango to Steckel, 4.

101 Verma to Himebauch, 2, 7; Mango to Steckel, 6–7; Verma to Stiffler, 5.

102 Verma to Himebauch, 7.

103 Rail and Jette, “Reflections on Biopedagogies,” 332.

104 State of Michigan Department of Health and Human Services, “Section 1115 Demonstration Extension Application, Healthy Michigan Plan,” 5

105 State of Wisconsin Department of Health Services, “BadgerCare Reform Demonstration Project Extension Application,” December 29, 2017 (revised January 19, 2018), Appendix B, 5, Appendix C, 5. Wisconsin is the only state of the six examined that has not accepted federal Medicaid expansion.

106 Verma to Himebauch, 7.

107 State of Michigan Department of Health and Human Services, “Section 1115 Demonstration Extension Application, Healthy Michigan Plan,” Attachment B, 3

108 Rail and Jette, “Reflections on Biopedagogies,” 330–2.

109 Mango to Steckel, 4, 6; State of Kentucky Cabinet for Health and Family Services, “Kentucky HEALTH Section 1115 Demonstration Modification Request,” August 24, 2016 (revised 3 July, 2017), 3; Kouzoukas to Taylor, 6.

110 Mango to Steckel, 7.

111 Mango to Steckel, 5.

112 State of Arizona Health Care Cost Containment System, “Arizona Section 1115 Waiver Amendment Request: AHCCCS Works Waiver,” December 19, 2017, Attachment 2, 2.

113 State of Indiana Family and Social Services Administration, “Amendment Request to Healthy Indiana Plan (HIP) Section 1115 Waiver Extension Application,” July 20, 2017, 8, 9; State of Arizona Health Care Cost Containment System, “Arizona’s Application for a New Section 1115 Demonstration,” September 30, 2015, Section 3, 9, Attachment 1, 1.

114 State of Arizona Health Care Cost Containment System, “Arizona’s Application for a New Section 1115 Demonstration,” Section 3, 7.

115 State of Arizona, “Arizona’s Application,” Section 3, 4.

116 State of Arizona, “Arizona’s Application,” Section 3, 6.

117 Rail and Jette, “Reflections on Biopedagogies,” 328–31.

118 Lupton, The Imperative of Health, 77–8.

119 Deanna L. Fassett and John T. Warren, “Rhetoric of an ‘At-Risk’ Educational Identity: Interviewing Jane,” Communication and Critical/Cultural Studies 2, no. 3 (2005): 239, 253.

120 Several Republican-led states have cued up proposals to (re)instate work requirements, and the US House of Representatives approved a 2023 debt ceiling bill that included a federal Medicaid work mandate; Megan Messerly, “Red States Hopeful for a 2nd Trump Term Prepare to Curtail Medicaid,” Politico, February 20, 2024, https://www.politico.com/news/2024/02/20/donald-trump-medicaid-states-00141397; Limit, Save, and Grow Act (2023), H.R. 2811.

121 Guth and Musumeci, “An Overview of Medicaid Work Requirements”