Republicans in Congress are resurfacing an old idea − requiring many adults on Medicaid to get a job in order to keep their health insurance. 

The work requirement is one of several ways the GOP is seeking to slash hundreds of billions of dollars from Medicaid, the government health program for low-income and disabled residents that covers about 1 in 5 Americans. Medicaid also covers pregnant women, 2 in 5 child births, and nursing homes for some low-income seniors and others.

Conservatives who support the idea say a work requirement would motivate people to seek employment and potentially secure health insurance through the workplace, saving taxpayers money. A Medicaid work requirement for healthy adults is about "empowering Americans" and would save more than $100 billion over a decade, according to U.S. Rep Dan Crenshaw, a Texas Republican, who introduced the legislation this month.

President Donald Trump has delivered mixed signals on what he plans to do with Medicaid.

In an interview with Fox News' Sean Hannity on Tuesday, Trump said, "Medicare, Medicaid – none of that stuff is going to be touched."

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But Wednesday, Trump endorsed the House Republicans' resolution that calls for deep cuts, stating Congress needs to pass the House budget and "move all of our priorities to the concept of, 'ONE BIG BEAUTIFUL BILL.'"

Critics warn the Medicaid work requirement, which surfaced during Trump's first term, failed to achieve significant savings while adding administrative costs and stripping away coverage of people who qualified. During the first Trump administration, 13 states sought a Medicaid work requirement but only Arkansas was far along enough to remove people from coverage.

Arkansas cut more than 18,000 residents from Medicaid within the first seven months of the program, often because people were unaware of paperwork requirements to keep their coverage, said David Machledt, a senior policy analyst at the National Health Law Program.

Medicaid work requirements are "designed to trip people up and then blame them for falling," Machledt said. "The lessons from everywhere where work requirements have been implemented show they don't accomplish their stated policy goals."

All eyes on Georgia

Georgia is one of 10 states that didn't expand Medicaid under the Affordable Care Act. In 2019, the Trump administration approved Georgia Pathways to Coverage program to extend Medicaid coverage to low-income, non-disabled adults who work at least 80 hours per month or qualify for exemptions such as being full-time students or volunteers. The Biden administration stalled the program, but Georgia sued and the program began enrolling people in 2023.

More than 6,900 residents are insured via Pathways, according to the Georgia Department of Community Health.

In January, Georgia Gov. Brian Kemp, a Republican, lauded the program's initial results.

"Despite the Biden administration's unlawful delay, Georgia Pathways has expanded healthcare coverage to thousands of low-income and able-bodied Georgians since it launched," Kemp said.

The program cost the federal government and Georgia more than $54.7 million by September 2024 – mostly administrative expenses. Less than half that amount – $19.5 million − was spent on health benefits expenses on behalf or enrollees, according to figures provided by GDCH.

The initial enrollment and program costs prompted Georgia's Democratic Sens. Jon Ossoff and Raphael Warnock and Sen. Ron Wyden, D-Ore. to request the U.S. General Accountability Office to investigate the program's administrative burdens and costs.

In a December letter to the GAO, the senators said the program enrolled 1% of people who would have been eligible if the state expanded Medicare coverage under the Affordable Care Act. The senators said hundreds of thousands of Georgians were uninsured as "taxpayer dollars are being routed into the pockets of eligibility system vendors and consultants."

Medicaid experts said the Georgia experience shows the high cost of starting and verifying work requirements.

"Georgia's Pathways to Coverage is the worst example of waste in Medicaid," said Joan Alker, a Georgetown University research professor. "It has been spectacularly unsuccessful in terms of providing health coverage for people who desperately need it in Georgia."

Georgia is pursuing changes to the Pathways program. Among the changes: eliminating the work-reporting requirement for parents of children under the age of 6.

Georgia also plans to reduce monthly eligibility checks for other enrollees. People would need to meet the work requirement when they sign up and when they renew coverage each year, according to a draft proposal of Georgia's plan.

In announcing Pathways' proposed changes last month. along with $3.8 million in funding for high-risk pregnancies, Kemp said his administration is aimed at "not only keeping families healthy together during a critical time of development, but also making an important investment in our state's future."

Legal advocates say changes are desperately needed. Some Georgia residents might initially qualify for Pathways but then get cut off during monthly eligibility checks, even though they submitted the required documents for their eligibility checks, said Cynthia Gibson, project director of Georgia Legal Services program.

As Congress considers expanding work requirements to more states, Gibson said Arkansas and Georgia provide real-world examples of how these programs work.

"It costs a lot more than people think it's going to cost, because the administrative costs are very high compared to the actual medical care that's provided," Gibson said. "It's not cost-effective."

About 2 in 3 on Medicaid already work

Despite the mixed records of the initial batch of 13 states that sought Medicaid work requirement waivers during the first Trump administration, more states are pursing these programs, said Jennifer Tolbert, deputy director, KFF program on Medicaid and the uninsured.

Idaho, Mississippi, Oklahoma, South Dakota and Tennessee all have submitted waivers to the Centers for Medicare & Medicaid Services to launch Medicaid work programs, Tolbert said.

About 2 in 3 people on Medicaid are employed full or part time, and others would qualify for an exemption from the work requirement because they are caregivers or students, according to KFF, a health policy nonprofit. Just 8% were not working due to inability to find work, retirement or other reasons, KFF said.

Still, even though Medicaid recipients typically work or qualify for an exemption, many would likely lose their coverage due to paperwork, Tolbert said.

"Many would be at risk of losing coverage just because of the red tape involved and the administrative burden of having to report on a monthly basis about work status or qualification for exemptions," Tolbert said.

Proposed Medicaid cuts would 'wreck people's lives'

While work requirements could potentially save some money, some House Republicans are looking at deeper cuts to Medicaid.

On Feb. 13, the House Budget Committee passed a budget resolution that called for the House Energy and Commerce committee to cut $880 billion from programs it oversees over the next decade. Among the programs the committee oversees: Medicaid.

In a statement, House Budget Committee Chairman Jodey Arrington said the budget resolution is pro-growth, pro-energy and pro-working family and cuts taxes, regulations and waste.

"Republicans in both chambers should follow Trump’s lead − endorse it, unlock the most consequential legislation in modern history and Make America Great Again," said Arrington, a Texas Republican. 

A representative of the House & Energy Committee did not immediately respond to questions from USA TODAY about how the committee might reach the the $880 billion in deficit-reducing cuts.

Among the range of proposals reportedly being floated include implementing a per-capita cap on federal funding for state Medicaid programs. Under such a proposal, states would need to pay for an increasingly large share of Medicaid funding, Alker said.

A per-capita cap is "a very draconian proposal that would end Medicaid financing structure that's been in place for 60 years," said Alker, executive director and co-founder of Georgetown's Center for Children and Families. "It would be a massive cost shift to state budgets."

According to a budget document posted by Politico, other proposals could include restricting provider taxes, cutting public health funding and adjusting payments for states that expanded Medicaid under the Affordable Care Act. House Republicans' plan calls for around $4.5 trillion in tax cuts offset with $1.5 trillion to $2 trillion in spending reductions.

The House floor could vote on the budget resolution as soon as this week.

Medicaid is jointly funded by the federal government and states. But the federal government has picked up a larger share of the total cost in the last decade and a half, Brian Blase, who runs the conservative think tank Paragon Health Institute, said Wednesday in a brief.

Federal spending on Medicaid nearly tripled from $210 billion in 2008 to $616 billion in 2023. The federal government paid 72% of total Medicaid costs in 2023, up from 60% in 2008, Blase said. The federal government's rising tab on Medicaid is "a key consideration for Congress as it evaluates various Medicaid reform proposals," Blase said.

If House Republicans implement deep Medicaid cuts, the consequences will be "devastating" for families and children, Machledt said.

"It would have decadeslong consequences and it would wreck people's lives," Machledt said.