The year is 2025, and sexual and reproductive health care access is under attack on all fronts. Millions of people across the country, and especially people of color with low incomes, are losing access to abortion, pregnancy-related care, gender-affirming care, and medications for chronic conditions. As we face a second Trump administration, the future of critical and often lifesaving sexual and reproductive health care can feel bleak in the “land of the free.”
Members of the 119th Congress are already discussing including Medicaid work requirements in a reconciliation package. Make no mistake: Medicaid work requirements would only serve to further efforts to all-but-eliminate sexual and reproductive health care access and further reproductive oppression in the U.S. As the country’s largest public health insurance program, Medicaid plays a critical role in the struggle for equitable access to sexual and reproductive health care. It covers more than 40% of U.S. women’s births and 65% of Black women’s births.* It is the leading source of family planning coverage in the U.S. All states provide access to lifesaving breast and cervical cancer treatment via Medicaid, and many programs cover aspects of gender-affirming care. Some also cover assisted reproductive technologies that are especially critical for people with chronic conditions and/or disabilities that affect fertility, as well as many LGBTQI+ people. Medicaid’s critical sexual and reproductive health coverage makes it a strategic target for those who wish to restrict access for millions across the country.
Most people in Medicaid and other safety net programs work if they can. Prior Medicaid work requirements mandated that people work a minimum number of hours each month to stay covered, yet many Medicaid beneficiaries work low-wage jobs with fluctuating hours week to week. Thus, compliance is often out of their hands. Those who do not work generally cannot due to poor health or structural barriers such as a lack of access to affordable childcare, transportation, or internet access. Women and LGBTQI+ people, and especially people of color and with disabilities, also face discrimination such as sexism, racism, and ableism that impede access to quality employment.
Medicaid work requirements are just severe Medicaid cuts by another name. Decades of research and experience demonstrate that work requirements in safety net programs create burdensome and confusing red tape, paperwork, and reporting requirements that result in sweeping eligibility losses and ensure that people in poverty stay in poverty. Take Arkansas, one of only 2 states to implement work requirements in a Medicaid context. In 3 months of 2018, over 18,000 people with low incomes lost their Medicaid coverage because they could not meet the new requirements. That is 18,000 people who lost access to affordable and comprehensive and affordable health coverage, including sexual and reproductive health care coverage, and suffered worse health and economic outcomes as a result. For example, people reported rationing their medications, delaying their care, and accumulating increased medical debt. More recently, under Georgia’s current “Pathways to Coverage” Medicaid work requirement program, only 5,542 of the 300,000 low-income Georgians who should have gained coverage through Medicaid expansion have been able to do so. And ironically, work requirements do not improve employment outcomes. By cutting off access to health care, work requirements make it harder for those who work to stay employed, threatening their economic security.
Medicaid work requirement proposals are modeled off of longstanding and similar requirements in the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) program, which have long undermined reproductive justice by impeding access to basic human needs. Congress imposed work requirements on SNAP (formerly known as the Food Stamps program) beginning in 1971, and TANF in 1996. Throughout the decades, SNAP and TANF work requirements have been hard to meet, especially for those who do not have equal access to the societal supports necessary to participate consistently (e.g., Medicaid beneficiaries), people with disabilities, and interpersonal violence (IPV) survivors, who often face abuse that interferes with work participation. TANF work requirement programs are often far from peoples’ homes or conducted outside of regular daycare hours, making it all-but-impossible for many, including parents, to satisfy them. Because safety net programs largely serve the same populations of people with low incomes, we already know that Medicaid applicants and enrollees would face many of these same barriers to Medicaid work requirements. Work requirements also neglect or discount caregiving responsibilities, which women disproportionately bear. Proposals to impose work requirements seek to systematically decimate coverage for and endanger the health and lives of these populations.
We know from experience that “exemptions” from safety net program work requirements are extremely difficult to obtain and do not work as intended. In addition to the issues addressed above, people who are pregnant, have disabilities, or have parenting or other caregiving responsibilities may struggle to prove that they qualify for exemptions. Beneficiaries also often experience significant power differentials with program caseworkers, who have a great deal of discretion in whether to grant work requirement exemptions, and often arbitrarily refuse them. For example, in a 2022 study, caseworkers screened few women for IPV, a TANF work requirement exemption, and did not consider them for exemption. When applicants revealed their IPV experiences, caseworkers still often refused waivers that they should have granted. These same power dynamics would likely restrict Medicaid beneficiaries’ ability to obtain pregnancy-related, disability-related, caregiving, or other exemptions that Congress has proposed in the past. Many people will fall through the cracks and lose their Medicaid coverage.
Medicaid work requirement proposals have long been a cornerstone in efforts to end access to affordable health coverage. In this moment, they will only serve to further decimate access to reproductive and sexual health care for people with low incomes, and especially parents, Black, Latine, and other people of color, and people with disabilities. That’s why we are calling on Congress to oppose work requirements as well as any other Medicaid cuts.
*Of note, women are not the only people who need sexual and reproductive health care. More inclusive data collection and analysis are needed to help us better understand how Medicaid serves the sexual and reproductive health needs of people across all gender identities.
This blog post was originally published in April 2023. It was updated in January 2025.
