There are a lot of problems with work requirements for Medicaid.

They aren’t necessary because the majority of people who can work, work already; they would increase the ranks of the uninsured; and despite what supporters think, they wouldn’t actually pull people out of poverty but could further hurl them into it.

But there’s also another big issue: Medicaid work requirements could increase racial disparities in health care.

Last week, the Michigan Senate passed legislation that instructs the state to apply for a federal waiver for Medicaid, so that Michigan can require people work 30 hours a week before before receiving heath insurance. But as Detroit Free Press Nancy Kaffer first reported, some people will be exempt from the requirements.


If someone lives in a county where unemployment is over 8.5 percent, they don’t have to prove they’re working to get medical help. While on its surface, this doesn’t seem like a horrible idea, the threshold actually ends up exempting counties that are rural and predominantly white, while counties with large Black communities still have to meet the requirements.

Most of the 17 counties with unemployment exceeding 8.5 percent also happen to be represented by Republicans — including a bill co-sponsor, state Sen. Wayne Schmidt, according to Great Lakes Beacon’s Danielle Emerson. ThinkProgress reached out to Schmidt’s office for comment but they did not immediately respond.

People living in cities with large Black populations — many of which also have large unemployment rates among Black communities — still have to meet the requirements, like Detroit and Flint.

“Detroiters living in poverty, with a dysfunctional transit system that makes it harder to reach good-paying jobs, won’t qualify for that exemption,” writes Kaffer. “The same is true in Flint and the state’s other struggling cities.”

This is especially damning for Flint, a city still recovering from a public health crisis that left residents with poisonous levels of lead in their tap water. And that crisis was a result of the state government disregarding the health of poor, Black residents.


Gov. Rick Synder (R) opposes work requirements and will likely veto the bill should the House pass it. But this situation isn’t limited to Michigan.

In a Washington Post op-ed, Centers for Medicare and Medicaid (CMS) administrator Seema Verma advocated for exemptions for Medicaid work requirements, noting that states should account for “local economic conditions that may impact an individual’s ability to find work.”

This could mean similar racial redlining happens in other states.

Certain populations, and in this case along racial lines, could be required to work while others are exempt — and not only from work or job training but burdens associated like paperwork. “Because of the demographics, you could have situations where the populations required to work are disproportionately African American,” George Washington University professor Sara Rosenbaum told Vox earlier this year.

We’ve already seen something similar happen in Kentucky with its Medicaid work requirements. The state’s 80-hours-per-month work rules goes into effect in July, but it does not apply to eight rural, majority white counties: Bell, Clay, Harlan, Knox, Leslie, Letcher, Perry, and Whitley counties.

A Kentucky government spokesperson told ThinkProgress in January they are exempting these areas from the “community engagement” requirement, so as not to influence the outcomes of an existing food assistance program these counties are participating in. These counties are exempt until 2019. Meanwhile, the work requirement is slated to first roll out in northern Kentucky, which includes Jefferson County where a larger share of Black Kentuckians live.


Intended or not, these are the risks associated with work requirements — and it’s important to consider as a lot of states are implementing this rule in state Medicaid programs. As people drop health insurance, existing health care disparities are further entrenched.