SCOTT SIMON, HOST:
Republicans say that work requirements in the states that expanded Medicaid will get able-bodied Americans of working age off the couch. That means 18 million people who get their health insurance through the state and federal program will have to prove they are working, volunteering or going to school 80 hours a month in order to keep their coverage. It was Robert Gordon's job to set up Medicaid work requirements in Michigan, and he hates work requirements.
ROBERT GORDON: We would have a more honest and more efficient policy if Republicans just kick people off Medicaid, plain and simple.
SIMON: Says other states are about to learn some very hard lessons about what is involved. Michigan Public's Kate Wells explains.
KATE WELLS, BYLINE: Before Michigan's previous governor, Republican Rick Snyder left office, he expanded Michigan's Medicaid program to include people making slightly more money. And in order to sell it to skeptical members of his own party, he made work requirements part of the deal. This was a big change that was statewide news at the time.
UNIDENTIFIED REPORTER: Starting in 2020, able-bodied adults ages 18 to 62 on Medicaid will have to spend 80 hours a month at work, school, an internship, substance abuse treatment.
WELLS: The work requirements went into effect after Snyder left office. And then Governor Gretchen Whitmer, a Democrat, who opposed work requirements, came into office, and she hired Robert Gordon, an Obama White House alum, to run the state health department. By that point, Medicaid expansion had brought some 700,000 more people into this program, way more than initially predicted. And budget hawks, like Jarrett Skorup up of the Mackinac Policy Center, a free-market think tank, were like, this is getting out of hand.
JARRETT SKORUP: Because at this point, it's such a big part of Michigan's budget. It's crowding out teacher pay. It's crowding out roads. It's required a hike in the income tax.
WELLS: Republican lawmakers in the state legislature argued that adding these work requirements would save the state money. And Gordon had seen what happened when Arkansas tried this. About 1 in 4 people there lost their coverage, even though many of them were already working.
GORDON: Because computers went down, because forms weren't clear, because they just never heard about it.
WELLS: Others in Arkansas should have qualified for medical exemptions that they never got, he said.
GORDON: Honestly, maybe they got sicker. Maybe they died because of this decision. That is not a hypothetical. That is something that happens in systems like this.
WELLS: The law was the law. So Gordon and his team in Michigan got to work.
GORDON: If the state can figure out on its own without having to ask you if you're working, that's great 'cause then you don't have to do anything. You had exemptions for people who were medically frail. You wanted to try to get that information from health claims, from doctors. There's a huge amount of technology that has to get reprogrammed. You have a way for people to get in touch if they have problems. There are audit processes. There are appeals process.
WELLS: They spent more than a year setting up these systems, and everything else had to go on the back burner for a while. Michigan had one of the highest Black infant mortality rates in the nation. Thousands of people were still dying from overdoses. But instead, the state health department had to focus on work requirements.
GORDON: Your first job is going to suffer.
WELLS: When the state's Medicaid work requirements finally went into effect in 2020, some 80,000 people were on track to be booted off the rolls.
GORDON: That's the population of the city of Flint who were on track to lose their insurance.
WELLS: It was a lower rate of coverage loss than Arkansas had.
GORDON: So that was, like, thumbs up.
WELLS: But eligible people were still falling through the cracks, Gordon said. People got confused by the reporting processes, researchers showed. They hit language barriers with the phone systems.
GORDON: And it still is going to be pretty catastrophe.
WELLS: But two months before Michiganders were actually going to start losing coverage, a federal judge shut the whole thing down, ruling that Michigan's work requirements violated the intent of Medicaid - to provide low-income people with health insurance. Now, in 2025, Congress and President Trump have changed the law, saying that Medicaid work requirements will reduce waste, fraud and abuse. But for Gordon, it feels like deja vu all over again, arguing that you're only going to go after the freeloaders who don't want to work and that the only people who'll lose coverage are the ones who don't really deserve it.
GORDON: It's about creating a series of fantasies and fictions, and there's a lot of waste associated with those fictions.
WELLS: Michigan spent more than $30 million setting up work requirements. Now the 40 states that have expanded Medicaid will have to spend hundreds of millions more verifying that able-bodied Medicaid recipients are working, volunteering, in school or exempt, even though the data shows that more than 90% of them already are.
For NPR News, I'm Kate Wells in Ann Arbor, Michigan.
SIMON: And this story comes from NPR's partnership with Michigan Public and KFF Health News. Transcript provided by NPR, Copyright NPR.
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