Doctors, patients and health experts are bracing for massive coverage losses as House Republicans are poised to impose Medicaid work requirements as part of the “Big, Beautiful Bill.”
They are warning that a blizzard of red tape and administrative hurdles will strip people of needed healthcare.
The requirements would apply to everyone aged 19 to 64, with certain exceptions. States wouldn’t be able to waive them. According to partial estimates released by Republicans on the Energy and Commerce Committee, nearly 5 million people would lose Medicaid coverage.
GOP lawmakers say they are fine with those consequences, even those who have said they oppose cutting Medicaid benefits, because the requirements will only target the “able-bodied” people who should be working but choose not to.
“I like work requirements,” said Rep. Don Bacon (R-Neb.). “People that are able-bodied, mentally healthy, and all that should be working if you’re working age. Able-bodied people still get Medicaid, but you should be looking for work, trying to improve your skills or working. And I think most Americans want that.”
Groups such as the disabled, pregnant women and people who are in prison or rehabilitation centers would be exempt from the requirements. Those people, Republicans say, are the truly needy.
But someone who qualifies would need to prove they are exempt, which would require submitting the correct forms and documentation—in the correct order—at the time they apply for Medicaid and after they are already enrolled.
GOP leaders even seem likely to move up the start date for the work requirements. That accelerated time frame would front-load much of the savings, but also the coverage losses, meaning millions of people could be losing Medicaid in the runup to the 2028 presidential election.
Work requirements currently account for the largest savings in the health portion of the legislation; about $301 billion over seven years. Those savings come from removing millions of people from coverage, and there is no provision in the legislation to connect them with jobs or other sources of coverage.
“It’s not like they’re saving money by reducing costs or making people healthier. If the feds are saving money, it’s because the states are spending it or people aren’t getting health care. I mean, there’s no magic efficiency in these proposals,” said Jennifer Wagner, director of Medicaid eligibility and enrollment at the Center on Budget and Policy Priorities, a left-leaning think tank.
Georgia is currently the only state with a Medicaid work requirement. It’s part of the state’s partial Medicaid expansion; people who earn up to the federal poverty level can be eligible for coverage, but only if they complete the requirements.
Tanisha Corporal, 47, of Atlanta, is a social worker who needed health insurance after her non-profit job ended last summer.
She said she submitted an application three times over the digital portal, only to have her file disappear. She appealed; her appeal was denied.
“I would email, wouldn’t get responses. Or I’d get, like, very short responses that were not were not clear, or were not true,” she said of her experience trying to navigate the state’s verification system.
She eventually spoke up during public comments about the program, and her application was finally approved in March. During those months, she went without insurance.
She postponed an annual mammogram she gets because of a family history of breast cancer. Her college-aged son dislocated his finger and was scared to go to the doctor because of the cost. She eventually paid the bill after her application for Medicaid was approved retroactively.
Opponents of work requirements say stories like Tanisha’s will be the norm nationwide if the legislation passes.
“What I believe you’re doing, not intentionally, is figuring out every way possible for them not to qualify, either because they can’t fill out the paperwork [or] they don’t know how to do it,” Energy and Commerce ranking member Frank Pallone Jr. (D-N.J.) said in the early morning hours Wednesday, as the committee was slogging through a marathon session to debate and advance the provisions.
According to health policy research group KFF, there is no epidemic of non-working adults on Medicaid.
According to a KFF analysis, nearly two-thirds of the 26.1 million adults ages 19-64 covered by Medicaid in 2023 were working; nearly three in ten were not working because of caregiving responsibilities, illness or disability, or due to school attendance.
“We’re talking about low-income people to begin with, often with very complicated lives. You know, shifting hours, if they’re in part-time work, shifting jobs. So, you know, any of those folks could, could easily fall through the cracks,” said Larry Levitt, vice president of health policy at KFF.
Work requirements also represent a major cost shift to states. According to the Georgia Budget & Policy Institute, spending on upgrades to Georgia’s online eligibility and enrollment system represents the largest proportion of total program costs. It was almost five times higher than spending on healthcare benefits for enrollees.
The legislation would provide $100 million for states to implement registration and enrollment verification — spread across 40 states and D.C. that expanded Medicaid.
Work requirements have been a central feature of the Republican vision of turning Medicaid into a welfare program for the disabled and most in need, rather than a health insurance program.
During the first Trump administration, the Department of Health and Human Services actively encouraged states to apply for waivers to institute them. Officials at the time argued that work requirements were a pathway out of poverty.
Arkansas was the only state to implement a work requirement. The program began in 2018 but was struck down by a federal judge in 2019. In just the first five months, more than 18,000 people lost coverage.
Only a very small share regained coverage the next year.