For many years, Eric Wunderlin's health issues made it hard to find stable employment.
Struggling to manage depression and diabetes, Wunderlin worked part-time, minimum-wage retail jobs around Dayton, Ohio, making so little that he said he sometimes had to choose between paying rent and buying food.
But in 2018, his CareSource Medicaid health plan offered him help getting a job. It connected him to a life coach, who helped him find full-time work with health benefits. Now, he works for a nonprofit social service agency, a job he said has given him enough financial stability to plan a European vacation next year.
"I feel like a real person and I can go do things," said Wunderlin, 42. "I feel like I pulled myself out of that slump."
Republicans in Congress and several states, including Ohio, Iowa and Montana, are pushing to implement work requirements for nondisabled adults, arguing that a mandate would encourage enrollees to find jobs. And for Republicans pushing to require Medicaid enrollees to work, Wunderlin's story could be held up as evidence that government health coverage can help people find employment and, ultimately, reduce their need for public assistance.
Yet his experience is rare. Medicaid typically does not offer such help, and when states do try to help, such efforts are limited.
And opponents point out that most Medicaid recipients already have jobs and say such a mandate would only kick eligible people off Medicaid, rather than improve their economic prospects. Nearly two-thirds of Medicaid enrollees work, with most of the rest acting as caregivers, going to school, or unable to hold a job due to disability or illness, according to KFF, a health information nonprofit that includes KFF Health News.
Existing efforts to help Medicaid recipients get a job have seen limited success because there's not a lot of "room to move the needle," said Ben Sommers, a professor of health care economics at the Harvard T.H. Chan School of Public Health. Most Medicaid enrollees already work — just not in jobs with health benefits, he said.
"The ongoing argument that some folks make is that there are a lot of people freeloading in Medicaid," he said. "That's just not supported by the evidence."
Using health care programs to encourage work
The GOP-controlled Congress could allow or require states to implement a Medicaid work requirement as part of revamping and downsizing Medicaid. The first Trump administration encouraged those work mandates, but many were struck down by federal judges who said they were illegal under federal law.
Policy experts and state officials say more attention should be paid to investments that have helped people find better jobs — from personalized life coaching to, in some cases, health plans directly hiring enrollees.
They argue that work requirements alone are not enough. "The move to economic mobility requires a ladder, not a stick," said Farah Khan, a fellow with the Brookings Institution, a nonpartisan think tank.
While Medicaid work requirements have been debated for decades, the issue has become more heated as 40 states and Washington, D.C., have expanded Medicaid eligibility under the Affordable Care Act to the vast majority of low-income adults. More than 20 million adults have gained coverage as a result — but Republicans are now considering eliminating the billions in extra federal funding that helped states extend eligibility beyond groups including many children, pregnant women and disabled people.
Only Georgia and Arkansas have implemented mandates that some Medicaid enrollees work, volunteer, go to school, or enroll in job training. But a study Sommers co-authored showed no evidence that work requirements in Arkansas' program led to more people working, in part because most of those who could work already were.
In Arkansas, more than 18,000 people lost coverage under the state's requirement before the policy was suspended by a federal judge in 2019 after less than a year. Those who lost their Medicaid health care reported being unaware or confused about how to report work hours. Since 2023, Arkansas has been giving Medicaid health plans financial incentives to help enrollees train for jobs, but so far few have taken advantage.
Some plans, including Arkansas Blue Cross and Blue Shield's, offer members $25 to $65 to complete a "career readiness" certificate. In 2024, some Arkansas health plans offered enrollees educational videos about topics including taxes and cryptocurrency.
Health plans don't have an incentive to help someone find a better-paying job, because that could mean losing a customer if they then make too much to qualify for Medicaid, said Karin VanZant, a vice president at Clearlink Partners, a health care consulting company.
Rather than offering incentives for providing job training, some states, such as California and Ohio, require the insurance companies that run Medicaid to help enrollees find work.
In Montana, where some lawmakers are pushing to implement work requirements, a promising optional program nearly collapsed after state lawmakers required it be outsourced to private contractors.
Within the program's first three years, the state paired 32,000 Medicaid enrollees with existing federally funded job training programs. Most had higher wages a year after starting training, the state found.
But enrollment has plummeted to just 11 people, according to the latest data provided by the state's labor department.
Sarah Swanson, who heads the department, said several of the nonprofit contractors that ran the program shuttered. "There was no real part in this for us to deliver direct services to the folks that walked through our door," she said. The state hopes to revive job training by allowing the department to work alongside contractors to reach more people.
The hunt for results
State officials say they don't have much data to track the effectiveness of existing job programs offered by Medicaid plans.
Stephanie O'Grady, a spokesperson for the Ohio Department of Medicaid, said the state does not track outcomes because "the health plans are not employment agencies."
Officials with CareSource, which operates Medicaid plans in multiple states, say it has about 2,300 Medicaid and ACA marketplace enrollees in its JobConnect program — about 1,400 in Ohio, 500 in Georgia and 400 in Indiana.
The program connects job seekers with a life coach who counsels them on skills such as "showing up on time, dressing the part for interviews, and selling yourself during the interview," said Jesse Reed, CareSource's director of life services in Ohio.
Since 2023, about 800 people have found jobs through the program, according to Josh Boynton, a senior vice president at CareSource. The health plan itself has hired 29 Medicaid enrollees into customer service, pharmacy and other positions — nearly all full time with benefits, he said.
In 2022, California started offering nontraditional health benefits through Medicaid — including help finding jobs — for enrollees experiencing homelessness or serious mental illness, or who are otherwise at risk of avoidable emergency room care. As of September, it had served nearly 280,000 enrollees, but the state doesn't have data on how many became employed.
The University of Pittsburgh Medical Center, which is among the largest private employers in Pennsylvania, running both a sprawling hospital system and a Medicaid plan, has hired over 10,000 of its Medicaid enrollees since 2021 through its training and support services. Among other jobs, they took positions as warehouse workers, customer service representatives and medical assistants.
The vast majority left low-paying jobs for full-time positions with health benefits, said Dan LaVallee, a senior director of UPMC Health Plan's Center for Social Impact. "Our Pathways to Work program is a model for the nation," he said.
Josh Archambault, a senior fellow with the conservative Cicero Institute, said Medicaid should focus on improving the financial health of those enrolled.
While the first Trump administration approved Medicaid work requirements in 13 states, the Biden administration or federal judges blocked all except Georgia's.
"I don't think states have been given ample chance to experiment and try to figure out what works," Archambault said.
KFF Health News senior correspondent Angela Hart contributed to this report.
Copyright 2025 NPR