Editor's note: This story was originally published by The Florida Trib

Florida lawmakers are considering a proposal to add work requirements to what is already one of the most restrictive Medicaid programs in the country – and one that a federal judge recently found is severely understaffed and overwhelmed.

Experiments with work requirements in other states have cost taxpayers tens of millions of dollars, with little to show for it besides costly consultant contracts, and those who keep an eye on Florida’s lead family welfare agency question how the troubled bureaucracy can handle another regulatory hurdle.

Two months ago, a federal judge excoriated Florida’s Medicaid system, finding that state officials illegally nixed vital health care coverage for pregnant and postpartum women, children with disabilities and impoverished families, and then left them to navigate an impenetrable, Kafka-esque state bureaucracy that barely functioned.

In a blistering 273-page decision, U.S. District Judge Marcia Morales Howard found the notices that state officials sent to nearly 500,000 people beginning in April 2023 alerting them they were losing Medicaid coverage were “vague, confusing, and often incorrect and misleading” and “border on the incomprehensible.”

Concerned and confused families who turned to the state’s severely understaffed call center – where wait times could stretch to six hours – frequently found little help: That center blocked more than one million calls in just two months in 2024, Morales Howard found. Those who managed to speak to an agent hardly fared better. Customer-service agents at times provided information that was “astounding in its inaccuracies,” Morales Howard wrote.

In legal filings, the state has argued Florida’s Department of Children and Families doesn’t have the money or the staff to comply with Morales Howard’s order barring it from booting families off Medicaid without adequate notices, which will have to be reissued to more than a million Floridians.

Against that backdrop, Republican state Sen. Don Gaetz has been pushing SB 1758, which would add work requirements to the state’s Medicaid program, a new bureaucratic hurdle that would have to be enforced – and a longtime goal of conservative think tanks and policymakers.

“How can we reasonably expect (the state) to successfully implement a complicated work requirement structure?” said Melanie Williams, policy director of the Florida Health Justice Project. “What priorities will be delayed? What safeguards will weaken? What vulnerable populations will fall through the cracks?”

Going above and beyond federal requirements

GOP lawmakers are proposing new work requirements for the program, advancing restrictions that go above and beyond the sweeping mandates implemented under a new federal law – and that advocates say would force recipients to work their way into the health care coverage gap, meaning they make too much to qualify for aid but not enough to afford private health insurance.

But that hasn’t stopped Florida legislators from pushing ahead with the proposal – despite not having a financial analysis of what it could cost the state.

Gaetz said his legislation is meant to create a “work culture” in the program.

“If you want to keep your Medicaid benefits and have the taxpayers continue to pay for your healthcare, you got to go to work,” Gaetz said.

Congress recently instituted new work requirements for states that expanded Medicaid, under the measure known as the “One Big Beautiful Bill Act.” Many of those who benefited from Medicaid expansion are childless, able-bodied adults. But Florida is one of just 10 states that has not expanded Medicaid – meaning the federal work requirements don’t apply – and in the view of advocates, would be counterproductive and harmful.

In past years, Florida’s Republican leaders rejected the push for work requirements – acknowledging that the vast majority of the state’s Medicaid beneficiaries are newborns and young children, pregnant and postpartum women, adults with disabilities and the elderly, and raising concerns that work reporting requirements could create a barrier to receiving vital prescription drugs, essential treatments and mental health care.

Childless, able-bodied adults under the age of 65 already cannot qualify for Medicaid in Florida, regardless of their pay. If the bill passes, advocates expect the Floridians who will bear the brunt of the work requirements are parents of children over the age of 14, particularly women.

Researchers found work requirements don’t work

Researchers have found that work requirement experiments in other states did not meaningfully increase employment rates long-term – though they did result in lost coverage due to red tape and administrative hurdles.

A program in Georgia resulted in that state spending twice as much on administrative costs as on health care, according to federal analysts. The Current and ProPublica found that consulting firm Deloitte has taken in tens of millions in tax dollars to build, manage and market that state’s Medicaid work requirement program – yet only a fraction of eligible residents have enrolled, due to technical glitches and understaffed state agencies. Deloitte also contracts with Florida on its Medicaid program.

Arkansas also attempted a work requirement, but a federal judge blocked the program after 18,000 people lost coverage in the first few months of the policy, due to the bureaucratic challenges of verifying eligibility.

The drive for work requirements in Florida reflects a yearslong, multipronged effort backed by conservative think tanks and deep-pocketed corporations to erode the social safety for poor and working class residents – from pushing work requirements for public benefits to weakening protections for workers and rolling back limits on child labor.

Some exceptions apply

Medicaid recipients represent some of the state’s most vulnerable people. Income eligibility for parents is limited to those making up to about 26% of the Federal Poverty Level, roughly $7,100 a year for a family of three.

The changes being pushed by Republican lawmakers would require adult Medicaid recipients up to age 64 to report 80 hours of work activities each month, including paid employment and other tasks like workforce training and education.

According to an analysis by the nonprofit research organization KFF, just 11% of Florida’s Medicaid recipients are adults without disabilities, and 68% of that population is already working.

The proposed work reporting requirements would apply to an estimated 111,789 people, according to a legislative staff analysis of SB 1758, representing less than 3% of the overall Medicaid population of more than 3.9 million Floridians.

There are some exemptions to the work requirements, including for pregnant and postpartum women, people with disabilities, their caretakers, and the parents and caretakers of children under the age of 14 – and people on their deathbed, among others.

Under a recently filed amendment to the bill, Floridians receiving hospice care who are expected to die “in 6 months or less” would also not be required to work.

“It is hard to grasp how we arrived at a policy that effectively asks someone facing the end of their life to prove they are dying quickly enough to keep their Medicaid,” said Sadaf Knight, CEO of the Florida Policy Institute, a nonprofit research and advocacy group. “It’s almost unfathomable.”

A ‘Catch-22’ for low income people

Researchers and advocates worry Florida’s proposed work requirements will be more likely to kick people off the Medicaid rolls through bureaucratic hurdles, rather than promote real self sufficiency and stability.

Florida has a history of denying even eligible people coverage because of errors in its own system.

Morales Howard, the federal judge, painted a grim picture of Florida’s Medicaid program and the state employees tasked with helping Floridians navigate it.

Given how complex it already is to decide eligibility, Morales Howard wrote, as well as “the immense time pressure on (call center) agents and their limited training, and the minimal oversight, it is not surprising that the evidence shows that callers with Medicaid eligibility questions likely receive confusing, inaccurate, incomplete, or contradictory information from call center agents on a regular basis.”

Acadia Jacob, advocacy director of Florida Voices for Health, asked lawmakers to consider how a mom fleeing an abusive partner might be affected by the changes.

“She’s lucky if she has a phone, if she has reliable internet, a computer,” Jacob said. “Ultimately, if one paystub is lost, one form is submitted late … she and her kids risk losing access to their care,” she added.

Susan Harbin, a lobbyist for the American Cancer Society Cancer Action Network, fears the work requirements will pose a barrier to care for cancer patients and survivors, threatening their recovery.

“Punishing people with cancer and other serious chronic diseases by terminating their health care will only make them sicker and less able to work, and will do nothing to lower the cost of health care for anyone,” Harbin said.

Analysts at the Florida Policy Institute project that the work requirements will actually increase the state’s uninsured rate – already among the highest in the nation.

With the state’s minimum wage increasing to $15 an hour this fall, parents working 80 hours a month would earn about $14,000 a year – too much to qualify for Medicaid but below the federal poverty level, making them ineligible for financial assistance on the federal Health Insurance Marketplace.

“If you do this work requirement, we set up a Catch-22, where they are no longer going to have health insurance,” said Senate Democratic Minority Leader Lori Berman. “Once you go to work, you are not going to qualify anymore for Medicaid in the state of Florida. And if you don’t go to work, you’re going to lose coverage as a punishment.”

Sen. Gaetz, the bill sponsor, did amend the measure to provide a “glidepath” for people who would work their way out of Medicaid eligibility, but who don’t have access to employer-sponsored health care or can’t afford it. Under Gaetz’ amendment, those Floridians would continue to be able to qualify for Medicaid – for up to a year.

JJ Holmes, a Florida disability rights activist and Medicaid recipient, fears that Florida’s experiment will replicate the “administrative maze” created by other states – and that people in need will lose coverage because of paperwork.

“Here in Florida, most adults on Medicaid are already working. And a lot of the rest are dealing with illness, disability, school or caregiving,” Holmes said. “They’re not sitting around – they’re drowning. And now we’re going to add a swim test.”

Kate Payne is The Tributary’s state government reporter. She’s spent her career in nonprofit newsrooms in Florida and Iowa and her reporting has run the gamut, from interviewing presidential candidates on the campaign trail to middle schoolers in the lunch line. Kate has won awards for her political reporting, sound editing and feature writing and was named 2024 journalist of the year by the Florida chapter of the Society of Professional Journalists. Kate’s previous newsrooms include the Associated Press and WLRN Public Media in Miami. Her stories and photographs have been published by The New York Times, The Washington Post, The Christian Science Monitor, NPR and PBS, and her reporting on the death penalty has been cited in a filing in the U.S. Supreme Court. She can be reached at kate.payne@floridatrib.org. The Tributary is a nonprofit newsroom producing high-impact government accountability and investigative journalism in the public interest. Based in Jacksonville, our mission is to shine a light on systemic problems and solutions, hold those in power accountable, and focus on under covered topics through collaboration with other news organizations and the community.