In the realm of public health policy, few have navigated the complexities of Medicaid regulations as adeptly as Robert Gordon, former Michigan state health director. During his tenure, Gordon spearheaded the implementation of a controversial Medicaid work requirement, a policy he inherited under a Democratic administration despite personal reservations. With a career rooted in federal health policy and a deep commitment to minimizing coverage loss, Gordon offers a unique perspective on the challenges and lessons from Michigan’s experience. This interview delves into the intricacies of enforcing such mandates, the financial and administrative burdens involved, the impact on vulnerable populations, and the broader implications for states facing similar federal requirements today.
Can you share what it was like to take on the role of Michigan’s state health director during the rollout of the Medicaid work requirement?
Stepping into the role in 2020, my main task was to implement a law that had been passed under the previous Republican-led administration. It required certain Medicaid enrollees to prove they were working or meeting other qualifying activities for at least 80 hours a month. Even though Governor Whitmer and I didn’t support the policy, we were committed to executing it in a way that minimized harm. My focus was on building a system to track compliance and exemptions while trying to prevent as many people as possible from losing coverage due to bureaucratic errors or misunderstandings. It was a tough balance—upholding a law I disagreed with while protecting access to healthcare for thousands.
What stood out as the most significant hurdle in setting up this system?
The biggest challenge was the sheer complexity of creating a system from scratch that could handle hundreds of thousands of enrollees. We had to build online and phone reporting tools, and those systems weren’t always reliable at first. Technical glitches could mean someone’s status wasn’t recorded correctly, putting their coverage at risk. On top of that, we were looking at projections of 80,000 to 100,000 people potentially losing insurance. That kind of scale—equivalent to the population of a city like Flint—was daunting. We worked tirelessly to troubleshoot issues, but the fear of mass disenrollment due to something as simple as a missed form or system error kept us up at night.
You’ve mentioned the $30 million cost to build this system. Can you explain how that money was spent?
That $30 million went into a wide range of efforts to make the system functional. A big chunk covered technology upgrades—reprogramming our outdated benefits portal and setting up call centers for people to report their status. We also hired dozens of staff for compliance reviews, audits, and appeals processes. Another portion funded training for local organizers who helped enrollees navigate the new rules, as well as redesigning forms and letters to make them clearer. Reflecting on it, I can’t help but wonder if those funds could have gone to other pressing health needs, like maternal health programs or addiction treatment, but we were bound by the mandate to prioritize this implementation.
How did Michigan attempt to simplify the process for Medicaid enrollees facing these new rules?
We knew the reporting burden could be overwhelming, so we took several steps to ease it. First, we set up automatic checks using existing state data—like employment records or food assistance programs—to confirm if someone was already working or exempt without them having to lift a finger. We also cross-referenced data from community colleges for students and medical claims for health-related exemptions. Beyond that, we redesigned all our communication materials. Forms and letters were rewritten to be straightforward and eye-catching, ensuring people understood what was required. Our goal was to reduce confusion and prevent unnecessary coverage loss due to paperwork issues.
What concerned you most about the possibility of people losing coverage due to small errors or system failures?
The risk of people falling through the cracks was my biggest worry. We’d seen what happened in Arkansas, where over 18,000 lost coverage in 2018 due to unclear forms, computer downtimes, or simply not knowing about the requirement. I was haunted by the thought that someone in Michigan could lose insurance—and potentially their health or life—because of a glitch or a missed notification. To counter this, we built in extra time for reporting, set up multiple ways to submit information, and had staff double-check cases before anyone was disenrolled. Still, no system is perfect, and the fear of unintended harm was always there.
How did focusing on the work requirement impact other public health priorities in Michigan at the time?
It was a major drain on resources and attention. While we were pouring energy into this rollout, critical issues like Black infant mortality—one of the highest rates in the country—and the ongoing overdose crisis were pushed to the back burner. Almost all the focus at the state health department was on getting this policy up and running, from staff time to budget allocations. Balancing these competing needs was incredibly tough. You’re forced to make trade-offs, and it pained me to see other vital programs sidelined when they could have saved lives or improved health outcomes.
When a federal judge blocked the work requirement in March 2020, how did that moment feel for you and your team?
It was a mix of relief and frustration. On one hand, I was thankful no one lost coverage—especially with the pandemic hitting just days later. Those 80,000 people who were on track to be disenrolled kept their insurance at a critical time. On the other hand, I had to face legislators and explain that the $30 million we’d spent, at their insistence, was essentially down the drain. Testifying about that was tough; there was a sense of wasted effort after a year of intense work. But ultimately, protecting people’s access to healthcare outweighed the frustration of the halted policy.
With the new federal law mandating work requirements across many states, what key lessons from Michigan’s experience do you think others should take to heart?
Michigan’s experience shows how incredibly hard it is to implement these requirements without significant coverage loss, even with the best intentions. States need to prioritize robust data systems to automatically verify compliance or exemptions—don’t rely on enrollees to navigate complex reporting. Clear communication is also critical; redesign forms and outreach to ensure no one misses a deadline due to confusion. Finally, be prepared for the administrative cost and the toll on other health priorities. It’s a massive undertaking, and states should brace for the reality that many will still lose coverage through no fault of their own, which can have devastating consequences.
Looking ahead, what is your forecast for the impact of these federally mandated Medicaid work requirements on public health nationwide?
I’m deeply concerned about the trajectory. The Congressional Budget Office estimates 5.3 million more uninsured by 2034, and in Michigan alone, state projections suggest up to 500,000 could lose coverage in the first year under the new federal rules. This isn’t just a number—it’s people who might delay care, get sicker, or face financial ruin. The administrative burden will be immense, and I worry states won’t have the resources to prevent mass disenrollment, especially in a post-pandemic economy where jobs aren’t always stable. We’re looking at a potential public health crisis, layered with inefficiency and confusion, unless there’s a serious push for exemptions or policy reversals.
