Mandatory Volunteerism: Take It Off the Back Burner

The almost daily barrage of bad-news bombshells from the nation’s capital invariably includes a familiar item or two.

Something we’ve seen before … in Trump 1.0.

Our reaction: We’ve dealt with it.  Declared it dead. Buried it so deep in the wilderness it will never be seen again. It can be put on the back burner for just a little while….

That’s what we all thought in 2021 when the political winds swept in a new administration. President Biden was determined to cleanse federal policy of attempts to undermine or erase the popular and effective Affordable Care Act and the companion “Medicaid expansion” law.

Set to be tossed over quickly were the Trump 1.0 regulations imposing unauthorized and preposterous exclusionary rules or unreasonable hurdles to healthcare programs that had been created, after all, to expand – not decrease – coverage for low-income people. See  5 Key Facts About Medicaid Expansion (April 25, 2025) Jessica Mathers et al, kff.org.

So, in Adios to Mandatory Volunteerism (August 12, 2021) FPLG Blog, we concluded: “It seems safe … at this point to say ‘adios’ to  mandatory volunteerism ….”

Then, on January 20, 2025, the political winds switched direction once again.

By the first Independence Day of Trump 2.0, a compliant Congress had included a “community engagement” (sometimes called a “work or equivalent”) mandate in a brand new statute. See H.R.1 – An act to provide for reconciliation pursuant to title II of H. Con. Res. 14 (aka One Big Beautiful Bill Act, OBBBA), 119th Congress (2025-2026), signed into law on July 4th.

Note that advocates, including the organized nonprofit sector, had ably persuaded House negotiators not to include this onerous “Medicaid expansion” eligibility obstacle in their final version. But it went to the Senate, which made the proposed reconciliation bill worse, not better. By the slimmest possible margin: 50-50, with the Vice-President as tiebreaker, the Senate voted “aye.”

We reported this development in Mandatory Volunteerism is Back: What’s Ahead? (July 17, 2025) FPLG Blog. “Looking back from our perch in July 2025,” we wrote, “ bidding mandatory volunteerism ‘adios’ in mid-2021 may have been too optimistic. Perhaps a better choice of words for a prediction or pronouncement about the volatile American healthcare system may have been ‘hasta luego.’”

The start date for the new statutory “work or equivalent” requirement is somewhat in the distance – namely: “beginning not later than the first quarter after December 31, 2026 (or earlier, at the option of the state).”

On that basis, we concluded our July 17th post last summer with the observation that “[t]here’s much more to discuss as the charitable community confronts this brand new chapter in the “mandatory voluntarism” controversy.***Passive preparation for compliance is not the only option. Buckle up.”

Not a New Chapter, A New Monster

With so many monstrous obstacles and challenges facing us each and every day, it’s tempting to put some of the daily bad-news dump on a back burner.

After all, we’ve dealt with resurrected carcasses of execrable and oxymoronic ideas from Trump 1.0. We thought Mandatory Voluntarism was dead and safely buried away. We were wrong. Our current response – namely, that we’ll get around to disarming it in due course – is inadequate for several reasons including, most particularly, because we’re dealing not with a mere reconstituted copy of the old Frankenstein, but an entirely new creature.

A key reason that this is a novel challenge is that the “community engagement requirements” of H.R.1 are not the same as the “mandatory volunteerism” of former law. That was a regulatory interpretation of the law in place before July 4, 2025; namely, the Affordable Care Act of 2010 and the companion Medicaid Expansion statute.

Federal judges easily overturned the absurd Trump 1.0 HHS rationale for imposing a work-or-equivalent requirement on sick and vulnerable poor people. See, e.g., Why the Court Once Again Struck Down Federal Approval of Medicaid Work Experiments (March 29, 2019) Professor of Law Emerita Sarah Rosenbaum, GWU, commonwealthfund.org; New Medicaid Work/Volunteer Court Ruling (April 10, 2019) FPLG Blog; and Mandatory Volunteerism: Still, A Bad Idea (May 11, 2023) FPLG Blog. See also 5 Key Facts About Medicaid Expansion (April 25, 2025) Jessica Mathers et al, kff.org.

Challenging a statutory mandate is different from objecting to a mere regulatory interpretation. This is a brand new Frankenstein.

It’s important to keep in mind that this new monster is just a small cog in a much larger assault on the nation’s healthcare system and infrastructure. See, for example, Trump’s team is using Project 2025 as a blueprint to make changes to federal health programs (February 21, 2025, 7:00 am EST, Stephanie Armour, KFF Health News, cnn.com; [“The rapid-fire adoption of many of Project 2025’s objectives indicates that Trump acolytes — many of its contributors were veterans of his first term, and some have joined his second administration — have for years quietly laid the groundwork to disrupt the national health system….”] (emph. added).

Distinguished healthcare policy experts are not ordinarily prone to hyperbole. Believe them.

Similarly, see Republican Health Coverage Proposals Would Increase Number of Uninsured, Raise People’s Costs (November 27, 2024)] Center on Budget & Policy Priorities. cpbb.org. This leading independent healthcare policy think tank analyzed the Project 2025 and the Congressional GOP proposals at the time of the 2024 Presidential Election.  They “…would undermine Affordable Care Act (ACA) coverage protections, make health coverage more costly and less comprehensive, shift more costs to states, and increase the number of uninsured people in the U.S.”

The charitable community is opposed to the big-picture plan of destruction – of course. But, for us, the small part of it that casually imposes on our sector (without our consent) the huge burden of a vast new army of “voluntoids” is a very big deal. It is an unreasonable and unsustainable anchor that could sink many of the nation’s charities  – already facing dire challenges directly caused by the federal government including the cut-off of huge swaths of government funding.

Time is of the Essence

Although the deadline is at the end of this year, there is a good deal of planning activity going on behind the scenes at the Department of Health and Human Services in which charitable-sector advocacy will be critical. See e.g., CMS Director Memorandum re: Requirements for States to Establish Medicaid Community Engagement Requirements for Certain Individuals [13 pp. PDF] (December 8, 2025).

“With federal Medicaid work requirements taking effect in 2027, states will spend the next year rapidly designing, integrating, and implementing the technology and data systems needed to support  [this] major shift….” Health care experts and think tanks, funded by foundations, are stepping up to help them make choices that, inter alia, minimize unintended coverage loss and other barriers …”

For example, different states might choose to implement a work requirement with reporting requirements that are easier or harder for applicant/recipient compliance. Project 2025, of course, mentions the flexibility to be granted to the states as a perverse way to achieve the long-time wish list of the conservative movement: “The plan, for example, calls for state flexibility to impose premiums for some beneficiaries, work requirements, and lifetime caps or time limits on Medicaid coverage for some enrollees in the program for low-income and disabled Americans, which could lead to a surge in the number of uninsured after the Biden administration vastly expanded the program’s coverage.”

According to Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit: ““These proposals don’t directly alter eligibility for Medicaid or the benefits provided, but the ultimate effect would be fewer people with health coverage. When you erect barriers to people enrolling in Medicaid, like premiums or documenting work status, you end up rationing coverage by complexity and ability to pay.”

Conclusion 

These few items are just the tip of the iceberg. There are many more aspects of the new Mandatory Voluntarism that must be addressed immediately by the sector that will be so unconscionably burdened.

For a start, there’s that army of “voluntoids” who are about to descend on, and overwhelm, many local 501(c)(3)s, particularly in areas with insufficient employment openings.  As nonprofit leaders well know, volunteers are not free labor. They are expensive to organize and supervise. There is also the extraordinary (and unwanted) duty to keep records and report to state agencies well enough so that individuals can qualify for, and receive, their needed benefits.

Tell the torch-bearing villagers to turn around and take their pitchforks home. We’re beyond the point where that will help. Let’s get to work.

– Linda J. Rosenthal, J.D., FPLG Information & Research Director