Equal Voice

The Safety Net’s Future: Ala. Is Latest Front in Battle Over Medicaid

March 21, 2018

Paul Nyhan
By Paul Nyhan
Manager of Storytelling

The battle over the future of the safety net is increasingly being fought in the states in 2018.

alabama state house

Community leaders and doctors working for equitable policies in Alabama are voicing concern about possible new work requirements for state residents who receive Medicaid. They say the requirements could actually put families in jeopardy. Photo source: Arise Citizens’ Policy Project

Alabama has joined a growing number of states proposing new work rules for Medicaid recipients, a move that will hit mothers, Black residents and rural families of all backgrounds harder than most, and threaten health coverage for up to 8,700 parents in 2018, advocates say.

Under Alabama’s new proposal, parents and caregivers who rely on Medicaid would have to work 20 to 35 hours a week, or comply with other requirements, such as showing they are looking for work, participating in job training, enrolled in education or volunteering. Medicaid is one of the largest parts of the safety net, a joint federal-state program that provides health insurance to roughly 74 million Americans.

Those new rules could leave parents in a dangerous limbo, since working the required hours could mean they earn too much to qualify for Medicaid, but too little to afford private insurance, according to an analysis released on March 20 by Arise Citizens’ Policy Project of Montgomery, Alabama.

These new rules would threaten one of the few assets the state’s most vulnerable families possess: health care, said Jim Carnes, policy director for the organization, which focuses on public policies for low-income families. Alabama already has the tightest Medicaid eligibility rules in the nation, tied with Texas, according to the organization.

“The goal of this cruel, counterproductive plan is to take health insurance away from thousands of Alabamians who are living in desperate poverty,” Carnes said in a statement.

The new rules, however, are designed to improve Alabama’s Medicaid program, according to Alabama Gov. Kay Ivey. The program would cover “able-bodied” recipients, and provide exemptions, including for people with disabilities, those caring for someone with a disability, elderly residents and some new parents.

“The governor’s instructions (for defined work requirements and increased co-pays) are aimed at continuing to increase efficiency and decrease costs related to Medicaid, all in an effort to be good stewards of taxpayer dollars,” a statement released by the governor’s office said.

The Alabama plan, which still requires review and approval by the U.S. government, is the latest front in a battle over the size and shape of the federal safety net. Republican leaders, such as U.S. House Speaker Paul Ryan, have been talking about overhauling welfare and federal social services this year.

States, though, are not waiting, instead moving ahead with their own plans, which could impact tens of thousands of families across the country in 2018 alone.

In recent months, Medicaid became a flashpoint in this fight, after the Trump administration opened the door for states to propose work requirements for Medicaid recipients. Since then the federal government has approved new work rules in Arkansas, Kentucky and Indiana.

These new rules represent changes to a key part of the federal safety net, with 1 in 5 Americans relying on Medicaid for health care coverage, according to The Henry J. Kaiser Family Foundation.

Congress has already targeted the health care program for deep spending cuts, proposing a budget in 2017 that would cut Medicaid by roughly $1 trillion over 10 years, echoing similar calls by the Trump administration.

But, that budget was a non-binding blueprint. Now, states are proposing and beginning to adopt tangible changes that will affect families.

The new work rules would create new barriers to health care, while not addressing other barriers that prevent families from lifting themselves out of poverty, such as job training and child care costs, according to a report released on March 20 by the Health Policy Institute’s Center for Children and Families at Georgetown University and Arise.

“As a pediatrician practicing in rural Alabama for 37 years, I have seen firsthand what happens when parents cannot access health care: Their children’s health suffers,” Marsha Raulerson, a doctor in Brewton, Alabama, added in the statement.

“If approved, the Alabama Medicaid work requirement would be a step backwards for a state that has been a national leader in covering children.”


Equal Voice is Marguerite Casey Foundation’s publication featuring stories of America’s families creating social change. With Equal Voice, we challenge how people think and talk about poverty in America. is the senior writer for Equal Voice. This story includes information from The Associated Press.

The Safety Net’s Future: Ala. Is Latest Front in Battle Over Medicaid