Medicaid Section 1115 Waivers: From work requirements to social determinants of health

Section 1115 waivers make it possible for states to seek approval from the Centers for Medicare and Medicaid Services (CMS) to test innovative approaches to delivering Medicaid services. These waivers allow states to test program elements that further Medicaid’s objectives but are otherwise unauthorized under federal law. Since the Social Security Amendments of 1965 (42 U.S.C. Section 1315), states have made use of waivers, shaped by federal political priorities, to test a range of approaches to administering Medicaid, including managed care programs, eligibility expansions, and new benefits. Waiver approvals are time-limited, and states must reapply upon their expiration. Waivers may be modified or terminated if the state fails to meet waiver conditions, or if the waiver is not achieving its intended goals.

Beginning in 2018, waivers were approved in 13 states to institute work requirements for Medicaid beneficiaries to receive insurance coverage. States that implemented these waivers saw thousands of people lose coverage with no appreciable increase in employment. Although nearly all of these waivers have been litigated and rescinded, Though nearly all of these waivers have been litigated and rescinded, Medicaid work requirements are now being implemented in Georgia, following a federal court ruling in August 2022.

Below, we review the recent history and current landscape of Medicaid Section 1115 waivers. We propose mechanisms for sustained advocacy on the part of the medical community, health law experts, researchers, and policy makers in opposing the use of waivers to impose work requirements and supporting the use of waivers to address social determinants of health (SDOH).