Medicaid Work Requirement Exemption for Depression Influenced by Location, Personal Political Affiliation

African American doctor writing on clipboard with patient in background
Physicians were surveyed regarding their responses to patients who wanted assistance with requesting a Medicaid work requirement exemption due to depression.

There was substantial variation in physician responses to patients who wanted assistance with requesting a Medicaid work requirement exemption due to depression, according to study findings published in the JAMA Health Forum.

Primary care physicians (PCPs) working in Arkansas, Kentucky, Indiana, and New Hampshire were mailed a one-page cover letter, four-page survey, and four to twelve-pages of information about their state’s policy on work exemptions in July and October 2019. The PCPs received a random clinical scenario and the PCP response to the hypothetical patient was assessed.

There were four random scenarios which varied by depression severity (minor vs major) and duration of patient-PCP relationship (new patient vs two years of contact).

A total of 715 PCPs responded to the survey at an overall response rate of 20.9%, with the cooperation rate at 83.8%, and the refusal rate at 3.8%.

Responders were aged mean 54 (standard deviation [SD], 12) years, 61% were male, they had graduated medical school 26 (SD, 12) years previously, 28% identified as Independent or other, 25% as Democrat, 22% as Republican, and PCPs said that 21% of their patients were covered by Medicaid.

Concerning work requirement policies in general, 54.1% of PCPs were uninformed about their role in the policy process and 54.2% felt like the administrative process was inappropriate.

PCPs were willing to help patients with minor depression 25.1% of the time and severe depression 46.0% of the time. There was a substantial variability in willingness to help, in which only 34.9% of PCPs in Arkansas were willing to help the patient with severe depression compared with 69.2% in New Hampshire.

Significant predictors of willingness to help included state (P =.01), perceived administrative effort (P <.001), and political affiliation (P =.002). Specifically, willingness to help was associated with practicing in New Hampshire (odds ratio [OR], 3.86; 95% CI, 1.48-10.0; P =.006), perceived neutral administrative effort (OR, 3.13; 95% CI, 1.60-6.14; P <.001), and perceived appropriate administrative effort (OR, 4.42; 95% CI, 2.36-8.30; P <.001). Compared with Democrats, Republicans (OR, 0.26; 95% CI, 0.11-0.57; P =.001) and Independents (OR, 0.39; 95% CI, 0.18-0.83; P =.01) were less willing to help.

This study was limited by its relatively low response rate.

These data indicated that there was substantial variation in the willingness of PCPs to help in obtaining a Medicaid work requirement exemption due to depression, indicating a review is likely needed for this policy.

“Although concerns about the demandingness of exemption procedures are entirely understandable, the willingness to assist beneficiaries qualifying for medical frailty exemptions is also determined by political views, and the perceived appropriateness of exemptions,” the researchers state.

“Work requirements are not the only case where personal preferences can make a difference between vulnerable populations retaining health care access or not, but the effect of these preferences needs to be considered more fully in program design and evaluations, as well as in the ongoing review of the legal justification for the policy.”


Schmidt H, Spieker AJ, Luo T, Szymczak JE, Grande D. Variability in Primary Care Physician Attitudes Toward Medicaid Work Requirement Exemption Requests Made by Patients With Depression. JAMA Health Forum. Published online October 1. doi:10.1001/jamahealthforum.2021.2932