At John’s Crazy Socks, more than half our colleagues have a disability and they depend on Medicaid for their jobs. I am not referring simply to medical insurance – which everyone needs – but to the services funded by Medicaid that make work possible for so many.

Yet Medicaid’s role in making work possible for people with disabilities remains almost invisible in our national debates.

In the debate over the big, beautiful budget bill, the Medicaid conversation mostly revolves around cost and coverage with heavy doses of political posturing and dire warnings. And that dispute takes our attention away from administrative changes being made outside the legislation. Beneath all the noise is a quiet truth: Medicaid is not just a safety net, it is an engine of opportunity for people with disabilities who want to work, live independently, and contribute fully to their communities.

Efforts to ensure that only those who are fully eligible and deserve Medicaid coverage get it may have the unintended consequence of denying coverage to the most vulnerable. In an effort to save money, experience shows we may lose money through increased administrative costs and lower than expected savings all the while having a devastating impact on people left with no coverage. In the worst cases, that could mean people losing jobs which will lead to higher costs.

I Know Medicaid

In the late 1980s, I led the Medicaid health programs in New York City and worked with the New York State legislature on Medicaid policy and laws. For many years, I helped build and lead Medicaid HMOs and worked with medical providers serving Medicaid patients. Today, I’m an employer of people with disabilities.

I’ve seen Medicaid not just from a policy desk and government perspective, but in our office and on the warehouse floor. I have a unique perspective on the Medicaid debate. We have enough sound and fury, let’s take a clear-eyed, fact-based look at how Medicaid supports employment for people with disabilities.

We’ll set aside the partisan debate and instead explore the structure, services, and real-world outcomes that make Medicaid essential to building an inclusive workforce.

The Basics: Receiving Medicaid

Many people receive Medicaid through their SSI coverage. SSI offers people with disabilities both cash and health insurance through Medicaid or Medicare. Some people qualify only for Medicaid. No matter, both approaches come with strict limits: if you earn too much, you lose your benefits. If you have too many assets – the limit is $2,000 set in 1979 – you lose your coverage.

As a result, people are often forced to choice between work and benefits. We have colleagues who would like to work more hours but turn down that opportunity because they cannot afford to lose their Medicaid coverage.

It is interesting and confusing to read how many members of Congress want to impose stricter work requirements on Medicaid recipients when more work may lead to a loss of coverage but not lead to private insurance coverage.

Let’s Look at the Numbers

Approximately 7.4 million Americans receive SSI benefits. Of that total, approximately 84 percent (6.2 million) have a disability. People with intellectual developmental disabilities (IDD) account for about 19.5 percent (818,179 people) of SSI recipients.

Yet Medicaid covers many more people with disabilities than those who qualify through SSI. Approximately 10 million Medicaid recipients have a disability. Of these, about 59% (approximately 5.8 million) were SSI recipients, while the remaining 41% (about 4.1 million) qualified for Medicaid on the basis of disability but did not receive SSI. More than 1.2 million Medicaid beneficiaries have intellectual or developmental disabilities.

When the budget bill seeks to reduce Medicaid spending by over $800 million by tightening eligibility and work requirements, what protections do people with intellectual disabilities have? What protections do these people who want to work have?

The Role of Medicaid in Supporting Employment

Medicaid is often thought of solely as a health insurance program. But for people with disabilities, it does much more. It provides long-term services and supports (LTSS) that make employment not only possible, but sustainable.

Whether through home-based services, job coaching, assistive technology, or transportation, Medicaid offers a broad range of tools that help individuals prepare for, find, get to, and keep a job.

Getting Ready: Laying the Foundation for Work

Before employment can happen, many individuals need preparation. In many states, Medicaid steps in with:

• Pre-vocational Services: Focused on building soft skills like communication, time management, and teamwork all essential for workplace success.
• Basic Life Skills Education: Help people develop daily living skills and adaptive strategies that support employment goals.
• Career Planning & Assessment: Funded under various waiver options, these services guide individuals in identifying strengths, interests, and suitable career paths.

These are not abstract offerings. They lay the groundwork for people to become not just job-ready, but confident and capable contributors to the workforce.

Finding the Right Fit: Medicaid-Funded Job Search Support

Once a person is ready to work, the next challenge is finding the right opportunity. In many states, Medicaid provides individualized services that include:

• Supported Employment: Includes job development, resume building, interview prep, and employer outreach.
• Customized Employment: Coaches work with both employee and employer to shape a role that plays to a person’s strengths.
• Benefits Counseling: Helps individuals understand how working will affect their benefits, reducing the fear of losing crucial coverage.

In many cases, these services are coordinated with state vocational rehabilitation agencies, but Medicaid fills the gaps and ensures continuity.

Getting There: Addressing Transportation Gaps

Transportation is a significant barrier to employment for many people with disabilities. Medicaid helps in several ways:

• Non-Emergency Medical Transportation (NEMT): Though primarily for healthcare, NEMT services can indirectly support work by keeping individuals healthy and work-ready.
• Waiver Transportation Services: Many states allow transportation to and from work to be covered under Home and Community-Based Services (HCBS) waivers. We have employees who benefit from this support.
• Self-Directed Budgets: Individuals can use funds to pay for Uber, taxis, or community rides as part of their employment plan.

Many of our employees at John’s Crazy Coks depend upon public transportation underwritten by the Medicaid program.

Staying Employed: Ongoing and Personalized Supports

Getting a job is just the beginning. Keeping it, thriving in it, and advancing takes sustained effort. Medicaid plays a central role here, too:

• Extended Job Coaching: Coaches visit the worksite as needed, helping employees learn tasks, resolve problems, and adapt to changes.
• Personal Assistance Services (PAS): Enable people with physical disabilities to perform essential work functions such as mobility, toileting, or accessing materials.
• Health Stability: Medicaid ensures individuals can access therapies, medications, and specialty care that allow them to manage conditions and avoid job disruptions.
• Peer Supports: Particularly for people with mental health needs, peer support specialists help others navigate stressors and maintain employment.

The vast majority of these services are delivered by non-profits who will suffer from cutbacks and that will affect their ability to deliver other services as well.

Real Lives, Real Impact

Many people with a disability are only able to work because of the health insurance support that Medicaid offers. Many are dependent not only on the medical care funded by the program, but also by the mental health services it provides.

Medicaid’s impact can be measured in success stories ere at John’s Crazy Socks and elsewhere:

• Andrew, one of our Sock Wranglers, depends upon the Suffolk County bus service to get to the job and his fares are underwritten by Medicaid.
• Gary, our Inventory Support Specialist, receives job coaching and housing support that is partially funded through Medicaid.
• An Anonymous Colleague is challenged with significant mental health challenges. She receives treatment that enables her to keep working thanks to her Medicaid coverage.

Here are some examples from outside our business:

• Joseph, once homeless, is now employed as a Peer Support Specialist after receiving supported employment through his Medicaid-funded behavioral health provider.
• Kushal, who has muscular dystrophy, uses Medicaid Buy-In and personal assistance services to maintain full-time work as a benefits counselor.
• Shawna, who feared losing coverage, used the 1619(b) provision to keep her Medicaid while starting a full-time government job.

These are not isolated cases. They are part of a growing movement toward employment for people with disabilities, made possible by the infrastructure Medicaid provides.

State Innovations and National Momentum

States like Washington, Vermont, and Wisconsin are aligning their state Medicaid programs with an “Employment First” vision. Washington, for example, boasts an 83% integrated employment rate among its waiver participants with developmental disabilities, more than triple the national average.

Federal initiatives, like the Medicaid Buy-In program (available in 46 states), further remove barriers by allowing people to earn income without losing health coverage.

A Smart Investment

Data shows that supporting employment through Medicaid doesn’t just change lives, it can reduce overall program costs. Workers tend to use fewer emergency services and report higher quality of life. We need more quality workers we need these people in the workforce. It’s not charity; it’s a smart policy.

Protecting People with Disabilities on Medicaid

If you present a plan to reduce Medicaid expenditures by over $800 million by tightening eligibility requirements, people will lose Medicaid coverage. That is the plan. Estimates range from 9 million to 14 million people will see their health insurance vanish.

The claim is that the people who lose coverage will be able bodied individuals who do not deserve Medicaid insurance. We need to be careful that we do not deny coverage to the most deserving in the process. And we need to make sure we do not spending dollars chasing pennies.

The current budget bill appears to provide exemptions for individuals with disabilities from the proposed work requirements. We need to ensure that those protections are clear, strong and in place in the final bill. And we need to be careful of artificial barriers and bureaucratic snafus that deny people coverage.

Arkansas established Medicaid work requirements in 2017. The result? Delays and disruptions in access to care for eligible beneficiaries due to administrative burdens. The work requirements also did not result in increased employment rates statewide.

Georgia implemented work requirements for its Medicaid expansion population and spent five times as much on administration than on health care benefits for enrollees.

Administrative Changes to Medicaid Could Undermine Employment

While budget negotiations are drawing headlines, another threat is emerging quietly: administrative decisions that are rolling back Medicaid’s ability to fund social support, particularly services that help people find and maintain employment.

During his first term, President Trump’s administration approved groundbreaking waivers that allowed states like North Carolina to use Medicaid dollars for non-medical services such as housing, food, transportation, and employment supports. These waivers recognized that health is shaped as much by social conditions as by clinical care.

At least 25 states followed suit. California’s $12 billion CalAIM initiative is a leading example, offering Medicaid-funded housing support, medically tailored meals, and case management for individuals with complex behavioral health needs.

But in March 2024, the Trump administration reversed course, rescinding the guidance that enabled these waivers and signaling that future requests would be considered more narrowly. The stated rationale: Medicaid should return to its “core mission” of medical care, with housing and nutrition left to other agencies even as the same administration proposes cuts to those very programs.

The implications are serious. Social service waivers have allowed Medicaid to fund the very supports that make employment possible for people with disabilities, services like stable housing, food security, and transportation assistance. Without them, individuals will struggle to stay healthy, let alone keep a job.

States like North Carolina, Oregon, and California have shown that these services not only improve lives, but reduce healthcare costs. North Carolina reported saving over $1,000 per participant annually in its Medicaid experiment, thanks to fewer ER visits and hospital stays.

Rolling back these initiatives now threatens to undo years of progress. People with disabilities risk losing the supports they depend on. States face uncertainty over billions of dollars in planned services. And employers like us may lose valued workers.

Medicaid must remain a tool for prevention, stability, and workforce participation, not just a program of last resort.

Final Thought: Medicaid Is a Launchpad, Not Just a Lifeline

If we want to live in a country where all people have a fair chance to contribute, then we must recognize the role Medicaid plays in making that possible. It is more than a safety net. It is the scaffolding that allows people with disabilities to rise, to work, and to thrive.

Policy debates will continue, but this truth remains: Medicaid supports work. And work, for people with disabilities, is not just about a paycheck; it’s about dignity, purpose, and community.

• Let’s build policies and programs that reflect that truth:
• Let’s ensure Medicaid eligibility rules support, not punish, work.
• Let’s preserve state flexibility that empowers innovation.
• Let’s rethink work requirements that undermine employment.

As the Senate takes up the budget bill, let’s make sure efforts to make sure that only eligible people receive Medicaid do not result in depriving people with disabilities the ability to work.

If you care about inclusion, contact your representatives. Tell them Medicaid must remain a launchpad for work, not a trapdoor out of healthcare.