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The writer is a contributing columnist, based in Chicago

Imposing work requirements in exchange for social benefits is as American as motherhood and apple pie. The idea is deeply rooted in American culture, especially in the US Midwestern states that helped bring Donald Trump to power. His “big, beautiful bill” — which includes one of the largest cuts ever in America’s social safety net — will force many recipients of public health insurance to prove they have a job to qualify.

So who are they, and how hard will it be for them to keep healthcare coverage in a country where a single accident or operation can bankrupt someone? They are nearly all of us: almost 70 per cent of those polled recently by KFF, the health policy research group, said someone close to them had received help from Medicaid (the taxpayer-funded health insurance programme for low-income and disabled Americans).

Even among Republicans, 51 per cent had been on Medicaid themselves or had a family member covered. In the Midwest in 2023, 25 to 30 per cent of the population was covered by either Medicaid or the children’s health insurance programme (Chip) — including several members of my family. Now, nearly a quarter of them will have to prove they work, study or volunteer for 80 hours a month, or are exempt from doing so. 

Brooke Rollins, the US agriculture secretary, recently suggested that Medicaid recipients could replace deported farm workers. But many recipients affected by the new law — mostly childless able-bodied adults — are already working. KFF estimates that 64 per cent of working age Medicaid recipients already have a full or part-time job. Another 28 per cent can’t work due to caregiving, illness, disability or school attendance. The American Enterprise Institute uses different data and finds that less than half of those affected already work.

Either way, many Medicaid recipients are clearly already working. So what impact will the new law have? When Arkansas experimented with work requirements, thousands lost Medicaid cover. And the Congressional Budget Office estimates the new requirements will increase the number of Americans without health insurance by 4.8mn. This will be achieved mostly by “driving people off Medicaid who can’t navigate the red tape”, Drew Altman, president and chief executive of KFF, told me.

I’ve interviewed Medicaid recipients (who didn’t want to be identified) in Ohio, a Republican state whose government believes Medicaid work requirements “give Ohioans the opportunity to live up to their God-given potential”. Most of them are working, but fear they will lose coverage because of bureaucratic hurdles. “Every new administrative requirement is another barrier [to coverage],” Teresa Lampl, an Ohio Medicaid expert, told me. “Notification comes through snail mail,” she adds, and if it’s a text message recipients may wonder if it’s a scam.

Melanie is an entrepreneur who has been on and off Medicaid for years. “I’m a libertarian, I don’t believe in big government and it’s hard for me philosophically to be on Medicaid,” she tells me. But she has to rely on it while she builds a new business. She’s worried that being self-employed will make it difficult to prove how many hours she’s working. If she can’t, she could lose coverage again.

Traci’s 28-year-old son works as a delivery driver. Medicaid pays for treatment for his bipolar disorder that would otherwise bankrupt the family. As a gig worker, she fears, he may struggle to document his work hours — or prove that he qualifies for an exemption due to mental illness.

“Everyone in America salutes the flag of work,” Altman says. That’s why Republicans in Congress were able to push through the new requirements. “But it makes no sense for states to mount Herculean efforts . . . that might result in just a tiny, tiny percentage [more] people working. The juice isn’t worth the squeeze.” 

The Medicaid recipients I interviewed don’t need a push from Congress to get jobs — they already have them. But they say they need Medicaid to keep working. Tying them up in red tape could yet backfire for Republicans. Even in the pull-yourself-up-by-your-bootstraps Midwest, millions can’t get healthcare without Medicaid. And that won’t change, just because Congress wants them to work harder.