One of the most pernicious elements of Republicans’ One Big Beautiful Bill Act is the emphasis it puts on work requirements. These requirements are peppered throughout the bill’s changes to social safety net programs, but most notable are the increased work rules for Medicaid.
The affordable health care program, which provides coverage to 71 million of America’s poorest residents, has operated without a work requirement for 60 years. If you qualified based on income and immigration status, you could enroll in Medicaid. Data shows that, despite the lack of a work requirement, the vast majority of Medicaid recipients were, in fact, working. Only 8 percent of adults under 65 on the program were retired, couldn’t find work, or weren’t working for some other reason. The other 92 percent of Medicaid recipients were working, acting as caregivers, or were ill or attending school.
But now, after the passage of the bill, adults under 65 without dependents under the age of 14 (there are a handful of other exemptions as well) will be required to prove that they work at least 80 hours a month if they want to receive basic health care through Medicaid. The moral implications alone are devastating: The ability to treat your diabetes, receive medication for your mental health disorder, or get a cast on your broken wrist will now be tied to your so-called productivity in the workforce.
But experts also say that, beyond the moral rot of the cuts, the change also poses a massive logistical challenge to states forced to build previously unnecessary work verification systems. “It’s just going to be a train wreck when [states] try to actually implement it,” said Matt Bruenig, the founder of the think tank People’s Policy Project.
States are required to implement Medicaid work requirements by December 31, 2026, giving them 18 months to build a verification system and iron out the manifold kinks that come with it (they may need an industrial-size iron). All states, however, are allowed to start work requirements sooner through the use of waivers, and some red states are likely to take advantage of that.
Bruenig pointed out some of the questions states, advocates, and Medicaid recipients will need to figure out before 2027: How will people definitively prove that they’re employed? Does informal employment count? Will Instacart drivers, who often wait for hours between grocery runs, be able to count that idle time toward their 80-hour-a-month total? Will people with seasonal work have Medicaid for the time they are working and then lose their coverage when they don’t?
“If you think about someone who cleans houses or mows yards, [there’s] not necessarily a lot of formal paperwork going on there to prove it,” he said. “But this goes beyond that, because it’s not just ‘are you employed.’ You have to prove that you worked a certain amount of hours during the month, and we really just don’t track that.”
Work requirements have been tried on the state level before, to devastating effect.
Some employers, especially larger ones, do track hours worked, reporting them quarterly to unemployment insurance systems. But otherwise, there is no universal recordkeeping that Medicaid recipients could easily access and submit.
“It just makes me reflect on my own interactions with state systems,” said Thom Walsh, a member of the Green Mountain Care Board, Vermont’s health care regulatory body. “When you file taxes or go to the DMV, those systems are not state-of-the-art … So a lot of people will lose Medicaid because it’s impossible to fulfill the paperwork requirements.”
Work requirements have been tried on the state level before, to devastating effect. During the first Trump administration, 13 states obtained waivers to place work restrictions on Medicaid within their system. Proponents of work requirements argue that the policy will grow the workforce and stimulate the economy. But the results from Arkansas’s work requirements attempt suggest otherwise.
Arkansas implemented its work requirement in 2018. Many Medicaid recipients never even learned about the change and were unable to submit the required documentation. An online sign-up portal also posed issues for those without internet access or technological literacy. All told, the work requirement pushed 18,000 Arkansans off of their Medicaid, with little success in increasing employment; one study found that the restriction had a negligible effect on employment numbers.
A court eventually struck down Arkansas’s work requirements, and most other states ended their equivalent programs or were forced to stop them when President Joe Biden came into office. Georgia is now the only state with an active Medicaid work requirement.
The initiatives are also incredibly costly for states to implement. In 2019, the Government Accountability Office (GAO) estimated that, were Kentucky to move forward with its proposed work requirement at the time, it would cost the state a whopping $271.6 million in administrative costs alone (like in Arkansas, a court struck down Kentucky’s work requirement plan). In the new law, the federal government earmarked just $200 million for all states to mitigate these costs; that’s only $4 million per state on average.
These cost estimates don’t take into account the downstream economic effects of kicking people off of Medicaid. “No individual is receiving a check from Medicaid. It’s money that is used to pay for care that’s been provided to patients,” explained Walsh. “That money is going to stop, and it’s hundreds of millions of dollars per year in my little state.”
According to Walsh, Vermont doesn’t have space in its budget to make up that difference, so hospitals will have to absorb losses on their own. That in turn could lead to staff layoffs or even hospital closures. In rural areas, where hospitals are sometimes the leading employer, whole communities could feel the cost of layoffs.
MEDICAID IS NOT THE ONLY FEDERAL PROGRAM that will have new work requirements imposed. The Supplemental Nutrition Assistance Program (SNAP) is now expanding its pre-existing work requirements. Now, veterans, the homeless, people between the ages of 55 and 64, and parents of children older than 13 can only receive SNAP benefits for three months in the span of three years if they don’t work. Once those three months end, so do their food benefits.
Housing advocates, too, are worried that their programs could be next. Hannah Adams of the National Housing Law Project said that the organization is monitoring both legislation and Housing and Urban Development (HUD) rulemaking for the introduction of both work requirements and two-year program time limits across federal housing programs. Some of the programs that Adams is keeping an eye on are Section 8, which helps house low-income renters, and HUD’s voucher programs, which support disabled people, former foster youth, and those fleeing domestic violence.
For now, housing advocates are waiting for the other shoe to drop as Trump’s budget is drafted, HUD rules are written, and legislation like the ROAD to Housing Act moves through congressional markups.
About the coming changes, Adams said: “We don’t exactly know what it’s going to look like, but we do expect that it will achieve the government’s current goal of kicking a lot of families that desperately need their assistance off the program.”
Work requirements are, in some ways, low-hanging fruit for Republicans who want to chip away at social safety net programs like Medicaid, SNAP, and housing assistance. The “bootstraps” rhetoric polls decently well: Health and Human Services Secretary RFK Jr., Centers for Medicare & Medicaid Services administrator Mehmet Oz, Agriculture Secretary Brooke Rollins, and HUD Secretary Scott Turner wrote in a New York Times op-ed that 62 percent of Americans support Medicaid work requirements. Yet, in the KFF poll they cite, that number falls down to just 32 percent once survey respondents learn that most Medicaid recipients do work and could lose their benefits due to the requirements.
Still, the Republican storytelling around work requirements harks back to an imagined America where blue-collar work gives even the poorest Americans a sense of national purpose and pride, and there are no barriers to finding such work. The narrative of welfare “freeloaders” who abuse the system is a persistent and persuasive one that makes it easier for Republicans to harm the programs, said Bruenig.
“I think [conservatives], for the most part, have an ideological opposition to these benefits, period,” he said. “And if they were fully free to do whatever they wanted to do and weren’t at least a little bit worried about some of the politics and getting all the votes they could get, that the core of the conservative movement would just get rid of their programs entirely. But because they can’t do that, they settle for cuts.”