The budget reconciliation bill passed by the US House of Representatives in May 2025 would introduce a mandatory federal work requirement for adults ages 19 to 64 to obtain and keep Medicaid coverage through the Affordable Care Act expansion. By the end of 2026, adults would have to work or participate in a work program or community service for at least 80 hours per month, be enrolled in an educational program at least half-time, engage in a combination of these activities for 80 hours per month, or have monthly income equivalent to working 80 hours at the federal minimum wage to qualify for Medicaid expansion coverage, unless they obtain an exemption based on being a parent or caregiver, medical frailty, or other characteristics.

The bill would apply the work requirement to those who are enrolled in or applying for Medicaid expansion coverage. Individuals would have to comply with the work requirement for at least one month between each redetermination of eligibility while enrolled and for at least one month immediately before enrollment. In this brief, we consider the bill’s implications for working adults and students, focusing on: (1) expansion enrollees with unstable employment, defined as those who work or attend school but do not meet the work requirement in every month while enrolled, and (2) adults who experience job loss or instability before enrolling in Medicaid.

Why This Matters

Work requirement proponents claim the policy would only deny Medicaid to so-called “able-bodied” adults without dependents who are not working. However, the policy could prevent many working adults from enrolling or staying enrolled in Medicaid because of the employment instability prevalent in the low-wage labor market, or because of health issues and caregiving responsibilities that force them to cut back hours or temporarily stop working.

We previously estimated that 5.5 to 6.3 million adults ages 19 to 64 could lose Medicaid expansion coverage in 2026 under a proposal similar to a 2023 House bill. Most of those losing coverage would be working, looking for work, or potentially meeting exemption criteria, but would still face disenrollment because of difficulties navigating processes for reporting work activities and exemptions. The reconciliation bill’s extension of work requirements to also apply at enrollment could lead to a larger reduction in Medicaid enrollment over time, depending on federal and state policy and implementation decisions.

Key Takeaways

Though 69 percent of expansion enrollees without dependents worked or attended school while enrolled in Medicaid, about 1 in 3 who worked or attended school would not have met the work requirement in one or more months because of unstable employment.

• Most expansion enrollees (69 percent) worked or attended school while enrolled, including 46 percent who would have met the proposed work requirement in every month of their enrollment and 23 percent who would have been noncompliant in at least one month, suggesting millions of working adults with unstable employment would be at risk of losing coverage.
• Among the remaining 31 percent of enrollees who neither worked nor attended school, more than two-thirds were not working because of a health problem or disability, difficulty finding work, or caregiving responsibilities.

Only 2 percent of enrollees were neither working nor in school and reported a lack of interest in a job as a reason for not working.

Many enrollees with unstable employment were in poor health, had irregular work schedules, experienced job loss or worked part-time involuntarily, or lived with disabled household members.

• Medicaid-enrolled adults with unstable employment were more likely than those who met the work requirement every month to have a disability (35 versus 20 percent) and to be in fair or poor health (23 versus 14 percent).
• More than half of enrollees with unstable employment (55 percent) lived with a household member who was disabled, age 65 or older, or a child younger than age 18, and thus caregiving responsibilities may have impacted their ability to work.

By imposing work rules before enrollment, the proposed work requirement would reduce Medicaid expansion enrollment among adults who worked or attended school in the months before applying, with the extent of the reduction dependent on state policy choices.

• Though 84 percent of adults worked or attended school at any point during the six months before enrolling in Medicaid, fewer (71 percent) would have met the work requirement in the month before applying.
• If states required applicants to demonstrate participation in work activities for six months before applying, 64 percent would be compliant in each of those months.

Workers who experience job loss would be at particularly high risk of being denied Medicaid.

• Nearly 1 in 6 adults (16 percent) experienced a job loss at some point during the six months before or the month of enrollment in Medicaid.

How We Did It

We use 2017–19 national data from the Survey of Income and Program Participation to examine how a work requirement, including at the point of Medicaid enrollment as proposed in the reconciliation bill, could affect Medicaid expansion coverage for working adults and students. Our analysis sample includes Medicaid-enrolled adults ages 19 to 64 in Affordable Care Act expansion states who are not parents or guardians of dependent children and are not eligible for Medicaid based on a disability. These adults are highly likely to qualify for Medicaid through the expansion and to be subject to work requirements under the reconciliation bill.