Empowerment or Administrivia?: The True Impact of Medicaid Work Requirements

The 2025 One Big Beautiful Bill Act (OBBBA) introduced sweeping changes to Medicaid, reshaping state enrollment policies and individual eligibility. Despite the Trump Administration’s early promise that they were “not going to touch” Medicaid, the OBBBA slashed key parts of the program, justifying it as trimming government spending. As of May 2025, 78 million Americans were enrolled in Medicaid and the coordinated Children’s Health Insurance Program. The OBBBA Medicaid policy changes are projected to lead to a 10 million increase in the country’s uninsured population by reducing federal Medicaid spending over a decade by a staggering $911 billion. The cuts primarily target adult enrollees with incomes between the Medicaid eligibility threshold and 138% of the federal poverty level who became eligible for Medicaid through the Affordable Care Act (ACA) in 2014. Allowing states to expand Medicaid to low-income adults drove the national uninsurance rate down significantly, but critics of expansion argue that it incentivized enrollees to intentionally restrict their income to remain eligible. The combination of budgetary contraction and social stigma surrounding public health insurance programs created a window for the Trump Administration to mandate work requirements for the first time in Medicaid’s history. The new policy imposes bureaucratic hurdles on Americans already working hard to make a living while struggling with major health challenges and threatens decades of progress in strengthening the healthcare safety net.

The OBBBA work requirement will apply to low-income adults aged 19 to 64 who are covered through the ACA Medicaid expansion and who do not qualify for exemptions. To remain Medicaid-eligible, adults must engage in at least 80 hours per month of work, education, community service,  or a combination of these activities. All states must implement the work requirement by December 2026. There is minimal precedent to understand the impact of this policy change on national uninsurance rates and public health. Still, health policy experts overwhelmingly agree that the work requirement will create more hurdles for enrollees and overwhelm state Medicaid administrators. The documentation process, which requires an eligibility redetermination every six months, combined with the pre-existing challenges faced by many Medicaid recipients, makes the work requirement unnecessarily burdensome. There are also questions about its effectiveness, especially given that the majority of affected Medicaid recipients are already working or otherwise fulfilling the requirement.

One of the key arguments against instituting a work requirement is its administrative infeasibility. All Medicaid recipients will need to be made aware of the requirement before it takes effect next year, and the mandated look-back period requires administrators to check if they met the work requirement in the months before they applied for Medicaid. Because Medicaid is administered at the state level, disparities in resources and data capacity will determine which states can adapt without creating paperwork-related coverage losses. As it stands, there is no streamlined Medicaid data system across states, raising concerns about higher rates of denials and lapses in care in states that have the greatest needs. When Arkansas attempted to implement a work requirement for its Medicaid program in 2018, confusing reporting requirements stripped coverage from over 18,000 people, with no associated increase in employment. Eligible low-income Medicaid recipients may not have the time or resources to fulfill new paperwork obligations, appeal denials, and claim exemptions, leaving them without healthcare coverage.

Although the OBBBA allows exemptions for Medicaid recipients who are pregnant, caretaking, or medically frail, among other things, the process for proving and granting exemptions is unclear. While individuals with a serious mental illness or substance use disorder are technically exempt, the work requirement and review process could pose a burden that causes Medicaid-eligible adults facing these challenges to lose coverage. That burden is particularly relevant, considering that 35% of covered US adults ages 19-64 have a mental illness, and 24% have a substance use disorder. Coverage loss due to red tape could be especially harmful to these individuals and their families, deepening the nation’s mental health crisis.

Far from empowering adults on Medicaid to find work, the OBBBA work requirement is a pipeline to uninsurance. Medicaid is a life-saving program, and making it more difficult to access under the guise of government savings is unconscionable. Putting up a maze of red tape does not promote work—it punishes those who are least able to advocate for themselves in an already complex system. Lawmakers and the public must recognize the OBBBA as the regressive policy that it is, rather than conforming to a bootstrap mentality. If this administration wants to make America healthy again, it must invest in healthcare access, not create barriers to it. 

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