In May, the US House of Representatives passed a reconciliation bill that would, for the first time, establish a mandatory federal work requirement for Medicaid.
Beginning in December 2026, adults ages 19 to 64 would need to demonstrate they’re working, volunteering, or participating in a work program for at least 80 hours per month or attending school at least half-time to be enrolled in the Affordable Care Act’s Medicaid expansion. People who are pregnant, care for dependent children or people with disabilities, have certain health conditions, or have other specified characteristics would qualify for an exemption. The bill would require people to comply with the work requirement for at least one month immediately before enrolling. Once enrolled, people would have to meet the requirement for at least one month between each redetermination of eligibility, which would occur every six months.
During the first Trump administration, a few states implemented Medicaid work requirements for adults who were already enrolled in Medicaid (but not, as proposed in the reconciliation bill, for applicants). As a result, thousands of adults lost coverage in Arkansas, including many who were already meeting the work requirements or who should have received an exemption. Others in New Hampshire and Michigan were on the verge of disenrollment when the work requirements were discontinued. Confusion about the policy and challenges navigating the work reporting systems contributed to coverage loss.
A recent Urban Institute analysis found that imposing similar work requirements at the federal level would lead approximately 6 million adults ages 19 to 64 enrolled in Medicaid expansion to lose coverage in 2026—even though most people at risk of coverage loss would be working, engaged in work-related activities, or would meet exemption criteria.
If Congress passes the reconciliation bill currently under consideration, coverage losses could exceed 6 million people and increase over time, given that the bill would also require people to comply with work requirements before enrolling. The very low enrollment in Georgia’s Pathways to Coverage program, which imposes a work requirement at the time of Medicaid application and requires applicants to submit proof of their work activities rather than assessing compliance automatically, highlights the potential pitfalls associated with imposing a work requirement at the time of enrollment.
In a new brief, we find that under Medicaid work requirements, many workers, students, and people experiencing job loss would miss out on Medicaid coverage because of how the requirements are structured and because of the administrative burden of complying. Workers and students with health problems would be especially at risk of losing coverage because they’re less likely to work or attend school steadily. Given data limitations, states would also face an uphill battle trying to identify people who meet the stated compliance and exemption criteria and ensuring they don’t lose coverage.
Medicaid helps people access the health care they need to work and go to school. Making Medicaid coverage harder to obtain and keep would undermine the stated goals of work requirements, ultimately making it harder for people to work.
Limited automatic exemptions for employment and schooling would lead many working people and students to lose Medicaid
Data matching, in which states can deem individuals compliant with or exempt from work requirements without requiring any further action or documentation from the individual, is an important tool to minimize coverage loss under work requirements.
Arkansas and New Hampshire automatically exempted or deemed compliant one-half to two-thirds of adults who were subject to work requirements based on available information from wage databases, Medicaid applications, and other state data systems. But between 72 and 82 percent of enrollees whose exemption or compliance status could not be determined automatically were unable to retain coverage or were on the verge of being disenrolled.
The federal reconciliation bill would encourage states to use available data to determine compliance with its work requirements when possible and provide states some funding for data-systems development. However, the extent to which states must use data is not specified, and the December 2026 implementation date would give states very little time to develop the data sources and systems needed for automatic determinations. If states can’t automatically determine compliance or exemption at rates comparable to states like Arkansas and New Hampshire with prior work requirements, risk of coverage losses would be higher.
Workers who are self-employed, work in the informal economy, and have nonstandard work arrangements (e.g., gig workers) and students are at particular risk of losing coverage because states are less likely to have data that could automatically exempt them from reporting. These workers and students could lose coverage not because they’re not in compliance with the bill’s requirements but because of the administrative barrier of having to take action to prove their compliance.
Requiring proof of work for at least a month before enrolling would create barriers for workers with unstable employment and those applying for Medicaid after a job loss
Though most nonelderly adult Medicaid enrollees work or are in school, many low-income workers have seasonal or temporary jobs or irregular job schedules and hours. Their employers often set work schedules with little advance notice. Many part-time workers balance work with caregiving responsibilities.
In our new analysis using the US Census Bureau’s Survey of Income and Program Participation (SIPP) data for 2017–19, we find 84 percent of Medicaid expansion enrollees without dependents worked or attended school at some point in the six months before enrolling. (The SIPP doesn’t capture whether people volunteered or participated in a work program for 80 hours.) But fewer (71 percent) would have met the bill’s proposed standards at the time of application to have worked 80 hours, attended school, or had income equivalent to working 80 hours at the federal minimum wage in the previous month.
Though most enrollees were participating in the activities required by the bill, more than 1 in 7 participating in those activities would have been deemed noncompliant because they would not have met the requirement in the month before enrolling. States would also have the flexibility to extend the lookback period for more than a month. For instance, if all states required compliance for six months before applying, 64 percent would be compliant, locking out nearly 1 in 4 adults who worked or attended school at some point in the six months before enrollment.
Medicaid expansion has been an important way people can get health insurance coverage after losing a job and their employer-sponsored insurance. It also helped many people during the early months of the COVID-19 pandemic, when unemployment rose steeply.
But workers facing job loss, either before applying for Medicaid or while enrolled, would be at particular risk of being denied Medicaid coverage under the bill’s standard because independently searching for a job is not a qualifying activity in the bill. In our analysis, most Medicaid enrollees who left a job did so because of completion of temporary or seasonal work, slow business conditions, health issues, or other involuntary reasons.
Proposed work requirements would disproportionately harm workers and students who are disabled or in poor health
Workers and students who don’t work or attend school consistently over a year would be at higher risk of not obtaining or losing Medicaid coverage under the proposed work requirements. Our analysis of the SIPP suggests Medicaid enrollees with less-consistent work and schooling patterns were more likely to be in fair or poor health, were more likely to have a disability, and used more health care than those working or attending school consistently throughout the year.
Losing access to health care that can help maintain or improve health could be particularly harmful to working people and students who have less-stable work as a result of their elevated health care needs. For those with functional limitations or chronic and acute physical, mental, and behavioral health conditions, losing Medicaid could be life-threatening. It could also cause financial and psychological distress for families and increase the strain on providers serving Medicaid enrollees and the uninsured.
Our analysis also suggests that health challenges—not a lack of interest in working—are a key factor that makes it difficult for some Medicaid enrollees to work at all.
The administrative burdens created by work requirements would make it harder for workers and students to access the health insurance coverage they need to work and go to school
Proponents of the reconciliation bill say work requirements are a strategy to get more people to work. However, evidence shows these requirements are unlikely to increase employment. To help more people work or attend school, Congress could instead explore evidence-based policies aimed at increasing employment, such as dedicating new resources to job training or work supports such as caregiving or transportation assistance.
Instead, we find that many people who are already working or engaged in the bill’s required activities would lose or be denied Medicaid coverage and access to needed health care. Research shows Medicaid expansion is associated with improvements in health and reductions in mortality. As such, the reconciliation bill’s work requirements could undermine workers’ and students’ health, making it more difficult for them to work or complete their education. For some people, it could even create barriers to getting diagnosed and treated for life-threatening illnesses.
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