Mandatory Volunteerism: Pushback Strategies?

“Many of the Republicans pushing for Medicaid work requirements … likely have no idea what it takes to comply with them. We do.” We Saw Medicaid Work Requirements Up Close. You Don’t Want This Chaos (Guest Essay) (June 8, 2025) Kevin De Liban, Esq. and Trevor Hawkins, Esq., The New York Times. 

These two former Arkansas legal-aid attorneys offered advice ahead of the Senate vote on H.R. 1, “One Big Beautiful Bill Act” (OBBBA). The House had included a “work-or-equivalent” mandate, despite a disastrous experiment seven years earlier during the Trump 1.0 administration’s flurry of approvals of “waiver” demonstration projects.

“The policy caused chaos for everyone involved: people receiving Medicaid, hospitals and health clinics, pharmacies, social services organizations and state agency caseworkers,” cautioned Mr. De Liban and Mr. Hawkins. The pair know all about this mess. They had successfully sued to have the earlier Trump 1.0 Arkansas mandate thrown out as “arbitrary and capricious.” See Gresham v. Azar (February 14, 2020), D.C. Court of Appeals, affirming their lower-court victory.

Their June 8th Guest Essay in the NYT was a warning and a plea to the nation’s senators not to repeat this “work-or-equivalent” mandate mistake. “As legal aid lawyers, we were on the front lines helping low-income people in Arkansas keep their health care coverage when the state rolled out work requirements in 2018,” adding: “No officials serious about governing should willingly create such problems for their own state.”

However, as we now know, H.R. 1 aka OBBBA, was signed into law on July 4, 2025: It includes a nonwaivable national mandate. See Mandatory Volunteerism is Back: What’s Ahead? (July 17, 2025) FPLG Blog. That statutory amendment to the Social Security Act places the charitable nonprofit sector in the United States in the fallback role: a Medicaid-expansion recipient, not otherwise exempt and who cannot meet the work or school option, must “volunteer.”

For many years, our sector leaders have vigorously advocated against this result which could overwhelm the nation’s 501(c)(3) organizations and expose them to unacceptable burdens, costs, and liabilities. See Mandatory Volunteerism, National Council of Nonprofits.

How Bad Was It ….?

A few nights ago, NPR’s Amanpour & Company had an 18-minute segment of Hari Screenivasan interviewing Kevin De Liban, who added more horrifying detail about what had gone wrong the first time around in Arkansas. See YouTube, Arkansas Lawyer on Medicaid Work Requirements: “Widespread Disaster & Chaos” (July 22, 2025). “Millions of Americans are at risk of losing their health care coverage, all because of President Trump’s domestic policy law, which mandates work requirements for Medicaid benefits nationwide….”

“A similar policy was implemented by Arkansas 7 years ago….” although over 90% were working, had caregiving responsibilities, were going to school, or had disabilities. The “problem” that the Arkansas officials had sought to remedy did not exist. Nevertheless, there were “.. mass coverage losses of 18,000 people … in only 5 months ….” Many individuals – who had been Mr. De Liban’s legal-aid clients – were swallowed up by a bureaucratic compliance black hole.

The “real fraud is that you would design a system to cut people off benefits in mass scales.” when they are otherwise eligible for Medicaid-expansion coverage.

Round Two of the Debacle

In our July 17th blog post  – Mandatory Volunteerism is Back: What’s Ahead?  – we wrote: “…There is little doubt that red-state governors will be tripping over each other in the competition to become the first jurisdiction to implement this odious and harmful Medicaid-eligibility requirement ….There’s much more to discuss as the charitable community confronts this brand new chapter in the ‘mandatory voluntarism’ controversy …. Buckle up.”

It seems that Arkansas didn’t wait for any Congressional action on the “work-or-equivalent” mandate: one week after Inauguration Day 2025, officials there submitted a brand-new waiver application, purporting to have fixed the federal judges’ objections to their Mandate Version One (2018). It’s called “Pathway to Prosperity Waiver” and proposes work and community engagement requirements for able-bodied Medicaid expansion adults (aged 19-64). See Request to Amend the ARHOME Section 1115 Demonstration Project Project No. 11-W-00365/4.

See also: Arkansas again seeks Medicaid work requirement waiver (January 28, 2025) Antoinette Grajeda, Arkansas Advocate and Medicaid Work Requirements Are Back. What You Need To Know (April 24, 2025) Ryan Levi, tradesoffs.org. It appears that the federal Department of Health and Human Services has not yet approved or acted upon this waiver request to date.

Meanwhile, several other states including Iowa and Ohio are reportedly are moving along these same lines.

The Road Ahead

In KFF analysts: Big Beautiful Bill is biggest change to U.S. health care since Affordable Care Act (July 9, 2025) Richard Payerchin, chief analyst Larry Levitt explains: “The One Big Beautiful Bill Act (OBBBA) will bring the biggest changes to the American health care system since the Affordable Care Act (ACA)….The bill was not framed as a health care effort, but it represents the biggest change to the health care system since ACA.”

“Key takeaways are: 

• OBBBA marks the largest rollback in federal health support, potentially increasing the uninsured population by 11.8 million and reducing federal health spending by over $1 trillion.
• Medicaid work requirements and changes to ACA Health Insurance Marketplaces complicate coverage renewal, potentially leading to increased uninsured rates.”

Conclusion

For an excellent “explainer” to summarize the Medicaid work-or-equivalent requirements under OBBBA section 71119, see the Legislative Update dated July 16, 2025 from BCR Group, 3 pp. PDF: Medicaid Work Requirements Under Section 71119 of the One Big Beautiful Bill Act.

It’s a helpful resource to review before we dive further into what, if anything, can be done to dislodge, defuse – or at least – delay this mess.

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