In March 2019, Judge James Boasberg halted work requirement implementation in Arkansas and Kentucky, finding that CMS had approved state waivers without adequately considering whether requirements would further Medicaid’s coverage objectives. By that point, Arkansas had terminated 18,164 people over seven months, primarily among individuals who were working or exempt but could not navigate the online-only reporting system. Those decisions changed work requirement politics. The threat of litigation became itself a policy constraint, shaping state choices even where no lawsuit was filed. The shadow of Stewart v. Azar extended far beyond the courtroom.
Under the One Big Beautiful Bill Act, the legal landscape shifts dramatically. Work requirements are now statutory mandates, not waiver experiments, closing the administrative discretion theories that succeeded in 2018 and 2019. But litigation remains a potential constraint through alternative frameworks: constitutional due process, disability rights law, and administrative procedure challenges to implementation rather than policy.
The Stewart Template#
The litigation originated with Kentucky HEALTH, Governor Bevin’s comprehensive transformation including work requirements, premiums, and benefit restrictions. CMS had approved the waiver weeks after Administrator Seema Verma issued guidance encouraging states to submit work requirement applications. Judge Boasberg found the approval “arbitrary and capricious” because it did not address projected coverage losses. Kentucky’s own application estimated 95,000 people would leave Medicaid by year five, with external analyses projecting 175,000 to 297,500.
When CMS re-approved with modified reasoning arguing coverage losses would be “dwarfed” by the 450,000 who would lose coverage if Kentucky ended expansion entirely, Boasberg rejected this too. Taking a cue from Chief Justice Roberts’ “gun to the head” language, he found the fiscal sustainability rationale would permit any waiver to be coverage-promoting compared to no coverage at all. The same day, he vacated Arkansas Works. New Hampshire fell on identical grounds months later. The D.C. Circuit affirmed, and the Supreme Court declined review after the Biden administration withdrew the waivers.
The template was clear: CMS could not approve work requirements without genuinely analyzing coverage effects. The issue was procedural, not substantive, but proved fatal across multiple cases. By the time COVID-19 triggered continuous enrollment in March 2020, no state was actively implementing work requirements under federal waiver authority.
The Changed Legal Landscape#
The shift from waiver to mandate closes the Stewart theory but opens others. Congressional statutes receive more judicial deference than agency actions, so challenges arguing work requirements are bad policy face much higher barriers. However, several alternative frameworks remain viable.
Due process theories target implementation rather than policy. Medicaid coverage constitutes a protected interest, and states that terminate coverage without adequate notice, insufficient cure time, or through systems individuals cannot reasonably navigate may violate constitutional requirements regardless of whether Congress authorized the underlying policy. Arkansas demonstrated this: many who lost coverage never received notice, did not understand requirements, or could not access the online-only portal.
The ADA and Section 504 of the Rehabilitation Act prohibit discrimination against people with disabilities in federally funded programs. When Arkansas implemented its exemption process, only 11 percent of applicants with disabilities obtained exemptions due to website difficulties, confusion, and inaccessibility. Verification portals inaccessible to people with vision or cognitive impairments, documentation requirements that effectively exclude people whose disabilities prevent compliance, and exemption processes that fail to provide reasonable accommodation all raise disability rights claims.
State constitutional provisions offer additional avenues in some jurisdictions, and regulatory challenges may target CMS rulemaking that exceeds statutory authority or fails proper procedures. The toolkit is different from the waiver era but far from empty.
Litigation as Multi-Dimensional Strategy#
Beyond legal outcomes, litigation serves political and advocacy functions. Court cases attract media coverage that administrative proceedings do not. When Boasberg struck down Arkansas’s requirements, news organizations reported coverage losses and human stories that policy briefs could not replicate. Discovery processes compel production of internal communications, coverage loss analyses, and deliberations that agencies would never provide voluntarily, generating evidence useful even when litigation fails on the merits.
Delay itself may be legitimate strategy. A lawsuit filed in early 2026 not finally resolved until 2028 may prevent years of coverage terminations regardless of ultimate outcome. For people who would lose coverage during that period, delay represents victory. Building the record for future challenges extends litigation’s horizon: judicial opinions on due process, disability accommodation, or administrative procedure become resources for subsequent cases.
The coordination between litigators and other advocates presents both opportunities and tensions. Litigation increases pressure on decision-makers and raises visibility, but can also lock in legal positions, divert resources, and create adversarial dynamics that complicate negotiating relationships.
The Shadow Effect#
Litigation shapes implementation even where no lawsuit is filed. State attorneys general assess legal vulnerability during design. Agency counsel review systems for due process adequacy. The memory of Stewart creates caution that explicit challenges alone would not produce. Design modifications to reduce legal exposure, including due process protections, accessible verification, reasonable cure periods, and meaningful good cause exceptions, benefit members regardless of whether litigation materializes. States that build these features to avoid lawsuits nevertheless provide protections that reduce coverage loss.
Preliminary injunctions represent the most immediate threat. Courts can halt implementation pending adjudication if plaintiffs demonstrate likelihood of success and irreparable harm. States considering aggressive enforcement must weigh the possibility that courts will stop their programs mid-stream, creating administrative chaos and political embarrassment alongside the legal setback.
The Bottom Line#
The Stewart legacy persists not as controlling precedent but as institutional memory shaping expectations about what courts might do. States designing implementation should assume legal challenge and build accordingly. Advocates should assess which states present strongest targets based on restrictive designs, poor due process protections, and inaccessible systems. For the policy landscape overall, litigation represents one tool among several: neither a silver bullet that eliminates work requirements nor a distraction from other strategies, but a constraint that can shape implementation toward less harmful approaches, document harms supporting future policy change, and protect individuals from unlawful terminations even where the underlying policy stands.
Source: MRWR-16E_Litigation_as_Policy_Tool.md Series 16: The Politics of Implementation GroundGame.Health Research Series on Medicaid Work Requirements