Medicaid Work Requirements Are Ethically Incoherent

“Functioning as our better selves leads to better outcomes for patients and everyone.”

Tarris (Terry) Rosell, PhD, DMin, HEC-C

Published April 2026

Bioethics often lives in gray areas. Increasingly, so do our patients – and our policies are not built to recognize them.

Recent data on Medicaid work requirements, reported in MedPage Today and drawn from a study published in Annals of Internal Medicine, bring this tension into sharp focus. More than eight million adults could be at risk of losing coverage, not because they are unwilling to work but because they fall into a familiar clinical gray zone: individuals with meaningful physical, cognitive, or mental health limitations who do not meet formal disability criteria. In other words, they are too impaired to consistently comply yet not impaired enough to qualify for exemption.

Three Obstacles to Work Requirement Effectiveness

For those working in clinical ethics, this population is not abstract. These are patients encountered every day – individuals managing chronic illness, fluctuating capacity, untreated mental health conditions, or functional limitations that complicate basic activities of daily living. They may be able to work intermittently, but not reliably enough to meet rigid hourly thresholds or navigate complex reporting requirements. Their vulnerability is real, even if it is not easily categorized. In fact, the limitation of rigid categorization makes them even more vulnerable.

This disconnect between policy assumptions and clinical reality is not new, but it is increasingly well documented. The premise of work requirements is that Medicaid enrollees need an incentive to engage in work. Yet data consistently show that most are already working, seeking work, in school, caregiving, or in poor health, with only a small fraction not engaged for reasons within their control (Pines, Forbes, 2026).

Real-world implementation reinforces this gap. In Arkansas, more than 18,000 people lost Medicaid coverage in just 18 months – not because they were not working, but because they could not navigate complex reporting systems (Pines, 2026). The program generated significant administrative costs without measurable employment gains. Similar patterns have emerged in Georgia, where high administrative spending yielded minimal enrollment and limited impact.

Beyond Effectiveness: Ethical Incoherence

Taken together, the issue is no longer simply whether these policies are effective, but whether they are ethically justifiable. National projections further underscore the stakes: the Congressional Budget Office estimates that work requirements could increase the number of uninsured Americans by millions over the coming decade (Pines, 2026). ‘

When a policy fails to achieve its stated goals yet predictably results in loss of coverage among individuals with significant health limitations, the ethical concern shifts. The question is no longer whether the policy is well-intentioned, but whether it is structured in a way that disproportionately burdens those it purports to help.

At that point, the issue is not simply one of effectiveness, but of ethical coherence. What emerges is a concerning duplicity: a policy framed as a remedy for systemic inequities, yet one that produces foreseeable harm among already marginalized populations. In practice, it risks functioning less as a pathway to independence and more as a form of structural penalty. In doing so, it shifts a program designed to expand access into one that restricts it – placing it out of reach for those it was meant to serve.

The Eligibility Gray Zone Penalty

This dynamic is particularly evident in what might be called the “gray zone” problem. Eligibility frameworks rely on binary distinctions – disabled or not, working or not – while clinical reality exists on a spectrum. Many individuals experience partial, intermittent, or context-dependent limitations that meaningfully affect their ability to work or comply with administrative requirements. When policies fail to account for this complexity, they do not simply overlook these individuals; they actively place them at risk.

Administrative burden further compounds this problem. Compliance extends beyond hours worked to documentation, reporting, and navigating complex systems. For individuals with cognitive limitations, mental health challenges, unstable housing, or limited access to technology, these requirements can become insurmountable barriers. As seen in multiple state implementations, coverage is often lost not because individuals are ineligible, but because they cannot successfully navigate the system (Pines, 2026).

What emerges is not simply a gap in coverage, but a pattern: those with the least capacity to comply bear the greatest consequences. Even when framed as an incentive, the policy risks functioning in practice as a penalty, one that falls most heavily on individuals already experiencing significant health and social vulnerability.

Clinical Consequences

For clinicians, these consequences are immediate and tangible. Patients will continue to seek medical care but often later, sicker, and with fewer options. Clinicians may find themselves navigating ethically fraught situations in which needed care is delayed or financially devastating. The resulting moral distress is not incidental; it is a predictable consequence of policies that create gaps between patient needs and available resources.

What makes this moment ethically significant is not only the scale of potential coverage loss, but the predictability of who will be affected. These are not individuals choosing not to engage in work, but individuals navigating complex health and life circumstances that make consistent compliance difficult.

A policy that neither achieves its stated outcomes nor accounts for this reality risks functioning less as a pathway to independence and more as a mechanism of exclusion. Once again, we are encountering systemic scapegoating of marginalized groups and bioethics is often called upon to navigate these gray areas in clinical care. Increasingly, we are being asked to confront them in policy as well. The question is not only how to care for patients who fall into these gaps, but whether we are willing to acknowledge when our systems are intentionally creating them.

Sources

Frieden J. 8 Million People at Risk of Losing Medicaid Under Work Mandate. MedPage Today.

Medicaid Work Requirements Go Live Soon. Here’s How Many Could Lose Coverage

Mrs. Tuttle is a 42-year-old woman who was recently diagnosed with early-stage breast cancer. After feeling a lump, she went to a free clinic for evaluation. She became extremely upset when she was told it was cancerous and that she would need treatment, as she had recently lost her insurance.

She had been on Medicaid for several years, but the new year brought the implementation of work requirements to maintain state Medicaid coverage, and Mrs. Tuttle is not currently employed. She had been a nurse but had to stop working when her father, who has dementia, was no longer able to live independently. She became her father’s full-time caregiver, with her long-term partner supporting her financially.

She was told that the cost of treatment without insurance could exceed one million dollars, which she cannot afford.

Aristotle said that justice was “giving to each that which is his due.” Justice and fairness do not mean that everyone needs to be given the same or equal amount, also known as egalitarianism. But the principle of justice “implies the fair distribution of goods in society and requires that we look at the role of entitlement. The question of distributive justice also seems to hinge on the fact that some goods and services are in short supply, there is not enough to go around, thus some fair means of allocating scarce resources must be determined.” (https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/articles/principles-bioethics).

Sharing the Pizza

One of primary aspects of fair distribution is first the determination of who the resources should be distributed among. Imagine you are with three of friends at a pizzeria for dinner. The pizza comes and is cut into eight pieces, and everyone agrees to split the bill. What would be a fair division of the pizza? The answer seems clear; everyone should get two slices of pizza.

But now imagine someone from the table next to you says the pizza looks good and asks if he could also have a slice? You have never met this person before, but he says that he is really hungry but forgot his wallet. Now, how should you share the pizza? Which of your group should give up one of his slices so that this new person can have some? Would that be fair? It would not seem unreasonable to say this person cannot participate or join your group, and you want to keep the pizza among yourselves.

In or Out Group

Humans are often looking for ways to establish and identify who is in their group and who is not. This is where concepts such as race, creed, religion, etc. originate from. How do you establish who is a member of your group and thus deserves to be considered when resources are being divided?

One way of doing this is by determining who is contributing and who is not. Imagine you are shipwrecked on a desert island with your pizza friends and several others. You and your friends make spears, swim out far into the ocean, and catch several fish to bring them back. You start to cook the fish, and the others ask if you are going to share with them. Maybe the members of the group did not have to go out and catch the fish, but you would hope they would help the group and contribute in another way. Maybe while you were fishing, they were making a shelter. Then you would be more likely to share your fish with them. But if they just want to lie in the sand and enjoy the sun, you would likely be less enthusiastic about sharing your fish. But also imagine someone got really hurt during the shipwreck and was not able to move. That person would maybe be an exception and could share in the fish while not working.

Fair ≠ Ethical

Needless to say, these situations can be difficult and full of ethical considerations. And while you may not want to share your fish, if someone was about to die, your human nature might overcome your hesitancy. Questions of fairness need to be balanced with other ethical concerns. Fairness is one consideration while other ethical principles are in play as well. Maybe it not fair that someone lying in the sand gets to eat the fish, but that does not make it fully ethical to let that person starve. The obligations to our fellow man may outweigh the need to thing to be “fair.”

Source: 

https://depts.washington.edu/bhdept/ethics-medicine/bioethics-topics/articles/principles-bioethics

Written By Ryan Pferdehirt, D.Bioethics, HEC-C, Vice President of Ethics Services, Rosemary Flanigan Chair & Cassie Shaffer Johnson, MA, Program Director of Ethics Services