What can be learned from states that made good faith efforts with work requirements?

Lessons from New Hampshire

From Don: in recent months this blog has warned, repeatedly, what a disaster work requirements will be for access to Medicaid. Nevertheless, the policy has been adopted by Congress. In the future, we will feature more work providing insight into how states can reduce the negative effects of work requirements. To be clear, this is not the optimal solution, but states are obliged to prepare as best they can for this future. Matt Darling starts by looking at the challenges New Hampshire experienced when it adopted work requirements in the past.

Medicaid work requirements keep backfiring—thousands lose coverage whenever states impose them. Work requirements are supposed to boost employment among Medicaid beneficiaries. In practice, paperwork issues cause people (including workers) to lose their health insurance. Nevertheless, on July 4th, 2025 President Trump signed HR 1, “The One Big Beautiful Bill” (OBBB), making Medicaid work requirements mandatory in all states. People who qualify for Medicaid through the Affordable Care Act expansions will now have to demonstrate that they have worked at least 80 hours every month (or qualify through alternative means such as documenting volunteer work, being pregnant, or participating in a training program) in order to continue to receive coverage.

States are going to struggle to implement this new mandate. Are there lessons from previous work requirement policies they can draw from?

During Trump’s first term, some states were given permission to add work requirements to their state Medicaid programs using Section 1115 waivers to pilot new Medicaid policies. States like Arkansas, Indiana, and New Hampshire were given permission to add work requirements to their state Medicaid programs. States that did manage to implement the new program generally saw poor results. However, these efforts by states can offer valuable insights for program administrators preparing to implement the new work requirement mandates.

For example, the Arkansas work requirement program did not succeed at increasing the number of people who were working; it just kicked people off Medicaid if they had not done the paperwork. Only half of Arkansas residents were aware of the new work requirements at all, and many people receiving Medicaid were unsure if the work requirements applied to them.

Because Arkansas failed to adequately inform people of the new program (and in many cases made it actively difficult to comply - for example, by limiting the hours where the website was “open”) the program effectively just arbitrarily removed people from Medicaid, whether they were working or not. In six months, almost 17,000 people lost their health insurance, many of whom were working at the time. Other states (such as Kentucky and Indiana) applied for waivers, but never implemented their work requirement programs due to suspensions issued by judges followed by the COVID-19 pandemic.

If you follow the discussion of work requirements, you have heard about the same few states a lot. It is easy to assume that states like Arkansas struggled because they made no effort to help clients to overcome work requirements. But what about states implementing the policy in good faith, who want to avoid a failure? In the past, states selected into work requirements, but now all states will have to implement them, even those where policymakers will be motivated to reduce the negative effects of the new policy.

New Hampshire was one of the last states to implement a work requirement program. State policymakers learned from the difficulties that Arkansas and other states ran into, and tried to create a plan that would effectively mitigate these problems. The New Hampshire approach included a wide range of activities, including direct phone calls to inform people of the new program, mailing letters to households, and weekly seminars.

These efforts failed:

• Phone calls: New Hampshire made over 50,000 phone calls to Medicaid recipients. However, they were only able to inform about 500 people of the new Medicaid requirements; 90% of phone calls were not answered to begin with. Of the people who picked up, 90% did not confirm their identity. Because Medicaid enrollment status is private information, phone callers were unable to tell people that they could be in danger of losing their health insurance.

• In-person meetings: Each New Hampshire district ran three information sessions on the new requirements each week for two months, but only 500 people attended in total. New Hampshire also sent people door-to-door to contact people at home, but of the 1,200 people who were visited in-person, only 150 people were contacted successfully.

• Letters: Medicaid beneficiaries were sent four separate letters informing them of the program. Unfortunately there is no direct evidence that can tell us how many people opened, read or acted on these letters.

Ultimately, New Hampshire’s Health and Human Services Director chose to suspend the program, as they did not receive any work verification information from 17,000 people, over two-thirds of the Medicaid beneficiaries who were supposed to document their work hours. The program was subsequently repealed by the New Hampshire House.

The sobering reality is that even in a state where policymakers wanted work requirements to work, they failed. Extra outreach was not enough to cushion the challenges for clients. But we can still try to learn from efforts in states like New Hampshire?

The letters that were sent by New Hampshire can give us a sense as to why these communication efforts struggled. An annotated version of the initial letter is below. Several features of the letter may have caused people to throw it away without reading it, or misunderstand what the letter requested:

• The first third of the letter - what someone would see immediately after opening the envelope - does not convey anything about the new work requirements to the reader. It merely tells the reader that the letter is important and that there is an option to request translations.

• The letter does not convey that the work requirements are a new program, so that someone who currently receives Medicaid might not realize that the program has changed and there are new requirements they have to follow.

• The second paragraph of the letter is primarily a list of possible exemptions from the program, which could inadvertently signal that there might not be any actions the reader needs to take.

• Only the final paragraph of the letter informs the reader that they are subject to the new requirements, and the specific language (“Your Community Engagement status is Mandatory”) is confusing jargon.

If the nationwide implementation of Medicaid work requirements in the next year is going to be successful, states will need to look at how the programs struggled in the first Trump administration. States can take several steps:

• Understand the magnitude of effort needed - Making 50,000 phone calls, as New Hampshire did, is a substantial effort. But if it only results in contacting 500 people, the effort failed. States need to recognize that they may need up to 100 contact attempts per individual to secure a single successful conversation. How many states will make such efforts?

• Look for regulatory workarounds - Because Medicaid enrollment information is protected health information, there are restrictions that limit how states communicate information to Medicaid beneficiaries. As noted above, callers trying to inform people about the new work requirements had to confirm the beneficiary’s identity first. It’s likely that many people being asked identity verification questions (for example, their birth date or social security number) would, reasonably enough, suspect a scam and hang up. Similarly, any information sent about an individual’s Medicaid status would need to be in a sealed envelope (as opposed to a flyer where the information can be read immediately).
  States can work around some of these restrictions. For example, instead of merely sending information in a sealed envelope, states could send everyone in the state a flyer or postcard about the changes that also notes that they might also receive a sealed envelope with specific information regarding their individual case.

• Coordinate efforts with other states - States that implemented Medicaid work requirements in the first Trump administration were working on separate programs on their own timelines. But now all states will be on a shared timeline and can coordinate some efforts. Maybe not all states will be on the same page, but they should be finding ways to share insights, and like-minded states should be pooling expertise and resources.

  For example, states can coordinate communications with neighboring states to ensure that people will hear about the changes on the radio and television. Much of the New Hampshire population lives in the Boston media market, and New Hampshire and Massachusetts (along with other New England states) could develop joint public service announcements and marketing materials that apply to Medicaid beneficiaries in each state.

• Carefully design and user test materials - Writing letters that effectively grab the reader’s attention and communicate the actions they need to take is both an art and a science. States should carefully design the letters to ensure that they are in plain language and use minimal jargon. Behavioral interventions, sometimes called nudges, can be integrated into the letters to encourage action. For example, the letters could include planning tools that not just tell people to document their work, but also schedule some time in the future to take that action. Ideally, these letters would also be tested - both with user testing before sending the letters and by testing letter variants in real time and switching to the most effective versions.

Implementing the new Medicaid work requirements will be a massive headache for states, and it’s likely that policymakers will face the same struggles states encountered during the previous administration. It may be that even with better preparation and more careful outreach, the best that states can do is soften the negative effects of work requirements. Good outreach may not be enough. But early planning and pooling of knowledge can help to ensure that the Medicaid work requirements do not destabilize Medicaid altogether.

Don again: here is an another example of principles and practices to improve outreach from the Center for Civic Design. You can read the full post here with excerpts below:

• Make it trustworthy. Help the recipients identify the office it came from with a few universally recognizable elements: the name of the office, contact information, and (as participants in our user testing told us over and over) “The form should have a seal on it to make it look official.”

• Explain the problem clearly. Write in plain language. Avoid (or explain) jargon. Write directly to the reader in active, positive sentences that tell them what they need to know and what they have to do.

• Be specific about the problem. Tell each person why they are getting this letter and show them what information it’s based on. Create separate letters for different problems, so everyone gets the details they need.

• Tell them how to take action successfully. If they have to return a form, tell them why and how. If there is an online version or more information on the web, give them a link (and a QR code for a web page). Make the requirements clear: Do they have to sign the form? Is there other required information? What is the deadline?

A. Use a departmental seal or logo to make the letter look official, not just a computer printout.
B. Put information about support and how to contact the office at the top of the page.
C. Open the letter by identifying and explaining the problem. The tone should be friendly, but urgent.
D. Speak directly to the recipient, not to a general “people covered by Medicaid.”
E. Spell out status and information from the record clearly. Don’t abbreviate or use jargon.
F. Add it up – don’t make people do calculations.
G. Tell them how to take action if they see something wrong. Don’t wait until the end of the letter.
H. When possible, tell them the date of the deadline, not how many days. At a minimum, put the date somewhere clearly on the letter.
I. Use bullets for lists. It makes each item stand out, so the list is easier to scan.
J. Tell them how to find more information – including links to online sources.

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