As State Medicaid Agencies prepare for the operational and policy shifts introduced by HR 1’s Medicaid Work Requirements, the stakes could not be higher. While the intent of these provisions is to encourage workforce participation, their real-world implementation risks leaving behind those who already face systemic barriers—particularly rural communities, people of color, and individuals with chronic conditions.
In a recent HMA webinar, “Work That Works: Creating Sustainable Employment Pathways for Medicaid-Enrolled Communities,” Shannon Joseph, Senior Consultant and Workforce Development expert at Health Management Associates (HMA), and Dr. Alicia Johnson, Managing Principal and strategic advisor on Medicaid transformation at HMA, led a dynamic conversation for state leaders and Medicaid stakeholders. Their core message was clear: with thoughtful design, states can transform work requirements from punitive compliance metrics into powerful tools for workforce development and economic mobility.
The Policy Landscape: HR 1 and State Readiness
HR 1 establishes new federal standards that require states to verify that certain Medicaid enrollees are meeting minimum work or community engagement hours as a condition of continued coverage. While exemptions exist for specific populations, the administrative lift, data infrastructure, and interagency coordination needed to operationalize these requirements are significant.
Historically, states that have experimented with work requirements, such as Arkansas, Kentucky, and New Hampshire, have seen coverage losses not because beneficiaries were unwilling to comply, but because systems were unprepared to support them. Barriers such as limited broadband access, low literacy rates, unstable employment markets, and health disparities disproportionately impacted rural residents and people of color.
Key Challenge #1: Avoiding Disproportionate Impact on Vulnerable Communities
One of the most pressing concerns is that work requirements may exacerbate disproportionate access. In rural communities, jobs that meet hour thresholds are often scarce, transportation options are limited, and childcare access is inconsistent. For people of color, historic and systemic barriers to employment persist, from lack of work credentials, to lack of tailored workforce programs. For individuals with chronic conditions or disabilities not formally classified as exempt, participation can be difficult or intermittent.
Dr. Johnson emphasized the importance of a community-based approach that leverages local resources and local social safety nets to increase participation and outcomes but developing targeted strategies that address the varying needs of the Medicaid community.
“We cannot simply apply a one-size-fits-all model. States must design implementation strategies that close population health gaps and overcome the social structural gaps in their systems, not widen them. Social Determinants of Health are not just passive background factors; they actively shape people’s ability to achieve and maintain good health and life outcomes.”
Best Practice: Conduct community-level impact assessments prior to implementation to identify geographic, demographic, and health-related disparities. Use this data to tailor outreach, exemptions, and workforce partnerships accordingly.
Key Challenge #2: Shifting from Compliance to Workforce Integration
Too often, states have approached work requirements as a compliance exercise—tracking hours, verifying exemptions, and ensuring federal reporting—without connecting to broader workforce development ecosystems. This narrow focus misses the opportunity to align Medicaid with labor, education, and economic development systems.
Shannon Joseph pointed to states like Louisiana, where cross-agency partnerships have begun to link Medicaid beneficiaries to workforce boards, training programs, and supportive services, “The most successful models are those where Medicaid is not working alone. When states braid resources and align objectives, work requirements can become a springboard for meaningful employment.”
Best Practice: Develop formal MOUs between Medicaid agencies, state workforce boards, Departments of Labor, and community colleges to share data, coordinate referrals, and leverage federal funding streams like SNAP E&T and WIOA.
Key Challenge #3: Building Administrative Infrastructure and Data Systems
Another central theme of the webinar was the need for robust data infrastructure. Many states lack integrated eligibility systems capable of tracking employment hours, exemptions, and participation across multiple programs. Without this integration, states risk errors, delays, and unnecessary disenrollments.
HMA highlighted the value of interoperable data systems and FHIR-based architecture that allow Medicaid agencies to exchange information with workforce agencies in real time. Digital equity must also be part of the conversation, especially in rural areas where broadband access remains a challenge.
Best Practice: Prioritize system modernization investments and interoperability pilots to build the technical backbone for equitable and efficient implementation such as the one in Georgia launched for the Pathways program.
Key Challenge #4: Partnering with Communities for Culturally Responsive Implementation
Dr. Johnson underscored that states cannot achieve equitable implementation from the statehouse alone. Partnerships with community-based organizations (CBOs), faith institutions, and local employers are critical to reaching populations who may be distrustful of government systems or unaware of new requirements.
Community partners are trusted messengers. They can bridge gaps in communication, help with navigation, and ensure that people understand both their obligations and opportunities,
– Dr. Alicia Johnson
Best Practice: Create local implementation collaboratives that include Medicaid staff, CBOs, workforce entities, and providers to co-design outreach and support strategies tailored to community needs.
Key Challenge #5: Aligning Metrics with Meaningful Outcomes
Finally, both speakers cautioned against relying solely on compliance metrics (e.g., hours reported, exemptions processed) to evaluate success. Instead, states should track workforce and health outcomes, such as employment stability, income growth, retention in coverage, and health status improvements. Shannon Joseph noted, “If our only measure of success is whether someone uploads their work hours, we’ve missed the point. The goal should be sustainable pathways to economic mobility and improved health.”
Best Practice: Develop a multi-dimensional performance dashboard that blends compliance data with workforce outcomes, health equity indicators, and beneficiary experience measures.
Solutions & Strategies for States: A Roadmap
Drawing from the discussion, HMA outlined a set of strategic recommendations for state Medicaid agencies:
- Conduct Equity Impact Assessments: Identify populations at risk of adverse impacts and tailor exemptions and support services accordingly.
- Align with Workforce Systems: Establish data-sharing agreements and coordinated referral pathways with workforce boards and community colleges.
- Invest in Data Modernization: Build interoperable systems to reduce administrative burden and ensure real-time verification.
- Engage Trusted Community Partners: Leverage CBOs and local institutions for outreach, navigation, and culturally responsive engagement.
- Shift Metrics to Outcomes: Measure employment stability, economic mobility, and health outcomes—not just compliance.
- Pilot, Learn, Scale: Start with targeted pilots in high-need communities, evaluate rigorously, and scale strategies that work.
HMA’s Role: Strategic Partner to States Developing Public/Private Partnerships to Build Genuine Pipelines of Work
HMA has deep expertise helping states design, implement, and evaluate Medicaid work requirement policies in ways that are operationally sound, legally defensible, and Medicaid Member-centered. Our team has supported states in:
- Conducting 1115 waiver design and evaluation,
- Integrating Medicaid and workforce systems,
- Designing targeted outreach strategies for rural and underserved populations,
- Implementing digital modernization projects, and
- Developing performance dashboards that focus on outcomes.
HMA brings both policy acumen and on-the-ground implementation experience, enabling states to navigate complex regulatory landscapes while advancing population health and real-world outcomes.
Learn More & Partner with HMA
If you missed the live webinar, you can watch the replay here.
You might also be interested in attending the HMA National conference, Adapting for Success in a Changing Healthcare Landscape.in New Orleans October 14-16, for our session on Making Medicaid Work Requirements Work, where we will draw on lessons from states like Georgia. Panelists will explore what to watch for in program design, including strategies to support workforce readiness, reduce administrative burden, and maintain access to care. Speakers include:
Online registration closes October 10, but if you act now, you can use the code FLASH25 for up to $475 off the standard registration fee for the full conference.
For more information about how HMA can support your state in strategic planning, operational design, impact analysis, and workforce integration, please contact our experts below.
