Medicaid Work Requirements Could Put 36 Million People at Risk of Losing Health Coverage

Recent proposals from Republican congressional leaders and conservative think tanks would cut Medicaid by taking coverage away from people who don’t meet unnecessary and burdensome work requirements.^[1] We estimate that 36 million Medicaid enrollees — including people in every state — could be at risk of losing their coverage under various proposals.

While not all of those at risk would lose coverage, many would. They would include people who cannot navigate complex work-reporting and verification systems each month, as recent proposals would require, along with other people who are unable to navigate the exemption process periodically to retain coverage and those who have been laid off or are otherwise unemployed, often temporarily. Depending on how states implement specific proposals, millions more people enrolled through Medicaid disability pathways could be at risk as well.^[2]

This analysis builds on past evidence that work requirements impose administrative barriers and red tape that lead to coverage losses among both people who are working as well as people the policies purport to exempt because they have caretaking responsibilities, disabilities, or illnesses that keep them from paid work. They also lead to coverage losses for those who are between jobs. Moreover, research shows that work requirements do not increase employment.^[3]

Many of the people who would lose their health coverage would lose access to treatment for chronic conditions such as cardiovascular disease, receive delayed diagnoses for cancer and face greater risks of death, and leave needed prescriptions unfilled. Others would accumulate medical debt or be forced to cut back on necessities like food and rent. A large body of research shows that Medicaid improves health outcomes, prevents premature deaths, and reduces medical debt and the likelihood of catastrophic medical costs.^[4]

Work requirements are simply another way to cut Medicaid — along with other recent Republican proposals that would impose artificial funding caps through block grants or per capita caps, and make cuts in federal funding alongside granting flexibility to take coverage away from certain groups or scale back on the health services covered by Medicaid.^[5] A recent list of spending cuts circulated among House Republicans suggested that a work requirement would slash $120 billion from Medicaid.^[6]

Policymakers should reject work requirements. Instead of needlessly putting tens of millions of people at risk of losing health coverage by saddling them with red tape and one-size-fits-all requirements that can make it harder for people to work, lawmakers should make it easier and less costly for people to access health coverage.

Recent Proposals Based on Faulty Assumptions and Failed Experiments

Proposals to take Medicaid away from people who don’t meet red tape-laden work requirements are based on the false premise that Medicaid enrollees do not work, when in fact data show that nearly 2 in 3 adult Medicaid enrollees aged 19-64 already work, and most of the rest would likely not be explicitly subject to the requirement based on having a disability, caring for family members, or attending school.^[7] (See Figure 1.)

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Work requirements are rooted not in reality, but in false stereotypes based on race, gender, disability status, and class. They ignore both the fact that most adults are working and the key reasons that people are not currently employed, including the impact of health conditions, disabilities, and the need to care for family members on people’s ability to work at various times; the instability of low-paying jobs; ongoing labor market discrimination that limits employment opportunities for people of color and women; and the lack of child care and paid sick and family leave.^[8]

Almost all enrollees either work or would qualify for an exemption under most proposals. Despite this, experience shows that a large share of enrollees would nevertheless lose coverage due to administrative burden and red tape. In Arkansas, about 1 in 4 enrollees subject to the requirements — some 18,000 people — lost coverage in only seven months in 2018 before a federal court halted the program.^[9] A large share of the enrollees who lost coverage in 2018 should have been eligible to retain coverage but did not reapply, according to data as of early March 2019, shortly before the program was halted.^[10]

New Hampshire implemented Medicaid work requirements in 2019 with the express intention of avoiding Arkansas’ failures by allowing more flexibility in reporting requirements and pursuing broader, more robust outreach efforts. But 2 in 3 enrollees subject to the requirements were likely to be disenrolled after just two months, amid reports of widespread confusion among enrollees about how to comply with the requirements. New Hampshire suspended the program, and a federal court halted the program soon thereafter.^[11]

Georgia, one of ten states that has not adopted the Affordable Care Act’s (ACA) Medicaid expansion, is the latest state to apply Medicaid work requirements. Unlike other states that added work requirements for existing enrollees, Georgia included work requirements as part of a waiver program to provide Medicaid to a new group of applicants^[12] with low incomes but requires people to show they meet minimum hours of work before they can enroll.

But 18 months after the program began, only about 6,500 people were covered, far below the 240,000 uninsured people estimated to be potentially eligible.^[13] Meanwhile, the program cost about $13,360 per enrollee through the end of the first year, with only about one-third of the spending on health care and the rest on systems modifications to implement work reporting, additional staff, and other administrative expenses.^[14] That’s far more than the roughly $2,490 per enrollee the program was initially estimated to cost in the first year.^[15] Potential enrollees expressed frustration at the complex rules and burdensome application process.^[16] Georgia’s experience provides additional evidence that work requirements prevent eligible enrollees from signing up, leading to low enrollment.

Recent proposals at the national level are similar to the policy put in place temporarily in Arkansas but even more expansive. First, they include a wider age range of enrollees who would be subject to the requirements. While Arkansas’ policy applied to people aged 19-49, the Limit, Save, Grow Act passed by the Republican-controlled House in 2023 included people aged 19-55.^[17] The Limit, Save, Grow Act is endorsed in both the Republican Study Committee’s fiscal year 2025 budget and the House Budget Committee’s fiscal year 2025 budget resolution.^[18] An even more recent bill introduced in December 2024 by Reps. Aaron Bean and Harriet Hageman would apply work requirements to people aged 18-65.^[19]

Second, recent proposals are not explicitly limited to people who have enrolled under the ACA Medicaid expansion, unlike the Arkansas policy; instead, non-elderly adults in multiple eligibility groups could have to prove that they are not subject to the work requirement to keep their coverage. States could use existing data sources to automatically exempt seniors, parents, children, and people enrolled through disability pathways without those individuals having to take any action, but this is not guaranteed.

Many people with chronic illnesses or disabilities that impede their ability to do sufficient paid work are enrolled in the Medicaid expansion group (because they do not meet strict criteria to qualify for Medicaid based on a disability or because it was simpler to apply through the expansion category) and would need to navigate a new system to show they are exempt. Moreover, some proposals would require even people enrolled through disability pathways to submit medical paperwork from a physician proving that they’re “unfit for employment.”^[20] This additional red tape is a barrier that’s likely to keep people out of coverage even if they are among those the policy promises not to impact.

Third, some groups exempt under the Arkansas plan, including postpartum enrollees, people identified as “medically frail,” and people receiving unemployment benefits, are not exempt under the recent national Republican proposals. Even if they were, Arkansas’ experience indicates that some people in these categories would not be automatically exempted by states and would instead have to take action to request and renew their exemptions.^[21]

Tens of Millions at Risk of Losing Health Coverage

We estimate that 36 million Medicaid adult enrollees would be at risk of losing health coverage under the recent proposals, representing 44 percent of all Medicaid enrollees. Of the 36 million adults at risk, 20 million are enrolled through the ACA Medicaid expansion, and 16 million are enrolled through non-expansion adult eligibility pathways. People in every state would be affected, with the share of total Medicaid enrollees at risk ranging from 17 to 41 percent in states that have not expanded Medicaid and from 34 to 63 percent in expansion states. (See Figure 2 and Table 1 for state-by-state estimates.^[22])

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As noted above, not all of those at risk would lose coverage, but the evidence indicates that many would. The number of people at risk, as well as the number who would lose coverage, would depend on the specific proposal and how the proposal were implemented. Notably, the estimates here do not include the millions of people enrolled through Medicaid disability pathways who could be at risk under the recent proposals. For more details on who is included in the population at risk, see the “Assumptions and Methodology” section below.

Research suggests that policies that take Medicaid health coverage away from people who don’t meet work requirements would especially harm some populations, including people with disabilities, women, people experiencing homelessness, and people with mental health conditions or substance use disorders.^[23] For example, many adults with disabilities are enrolled in Medicaid through the expansion or non-expansion adult group pathways because they have not yet succeeded in getting a disability determination to enroll through a disability pathway, or because they already qualify based on income and do not need to enroll through a disability pathway. These Medicaid enrollees with disabilities would therefore still be at risk of losing coverage even if disability pathway enrollees were automatically exempted.^[24]

Even though proposals may include exemptions for some in these groups, evidence from states that have implemented such policies shows that many people are nevertheless likely to lose coverage. States often lack the capacity to hire sufficient staff to respond to people’s questions or to manage work-reporting systems and the exemption process. People who have fewer transportation options or live in rural areas,^[25] face language or literacy barriers, are in poor health or have limited mobility, or have limited internet access^[26] would face particular obstacles to understanding the new requirements and navigating reporting systems, applying for exemptions, and collecting the verification needed to prove that they meet an exemption criterion.

Moreover, when people are ill, their ability to navigate these systems would be particularly impeded, putting their coverage at risk at the point they need it most. Taking coverage away from people who are chronically ill is counterproductive to their ability to work.

Young adults and children would also be harmed. While young adults whose parents have employer coverage can simply stay on their parents’ plans, young adults who need Medicaid would have to successfully navigate complex paperwork requirements. Children whose parents are uninsured due to burdensome work requirements would be more likely to go uninsured themselves.^[27]

Work requirements have no upside. Medicaid work requirements do not increase employment, research shows,^[28] and the Congressional Budget Office concluded that the 2023 House bill would lead to coverage loss with “no change in employment or hours worked.”^[29] Instead, work requirements strip health coverage from people with low incomes — most of whom are already meeting or exempt from the requirements — leading to gaps in care that damage their health and financial security and make it harder for them to find or keep a job.^[30]

Assumptions and Methodology

These estimates define the population at risk of losing coverage as adults aged 19 to 64 in Medicaid who are not enrolled through disability pathways. Within this group, we provide separate estimates for adults enrolled through the Medicaid expansion (i.e., expansion adults), who are most likely to be at risk of losing coverage, and for adults enrolled through other non-disability pathways (i.e., other adults), most of whom are parents, pregnant, or in the postpartum period.

Estimates for expansion adult and total enrollment are based on administrative data from June 2024.^[31] To estimate other adult enrollment in June 2024, we calculate the state-by-state proportion of other adults among all non-expansion Medicaid enrollees using fiscal year 2022 data,^[32] and then apply these proportions to the number of non-expansion enrollees in June 2024.^[33] Note that in general, enrollment is likely to be lower today than it is in the June 2024 data, as the unwinding of the Medicaid continuous coverage provision was still being implemented by states as of June 2024.

These estimates differ from our previous estimates in April 2023, which were specifically tied to the Limit, Save, Grow Act of 2023.^[34] Instead of estimating a specific proposal now, we include a larger group of enrollees who could be subject to the requirements, and we also make different assumptions about the degree to which states would automatically exempt enrollees when they implement the requirements. If in the future an analysis tied to a single specific proposal seems warranted, the estimates here can be refined.

Our previous estimates excluded parents of dependent children aged 17 and under, who were exempt under the Limit, Save, Grow Act, while the estimates here include all expansion and non-expansion adults, including parents, except for those enrolled through a disability pathway. Non-expansion adults who are not enrolled through a disability pathway are predominantly parents, making them less at risk of losing coverage under proposals that exempt some or all parents. But not all previous proposals have exempted non-expansion adults or parents, and some have exempted only parents caring for young children.^[35] Even under proposals that do exempt parents, parents who are exempt may still lose coverage if states require them to document their exemption.

Our previous estimates were limited to those aged 19-55, as specified by the Limit, Save, Grow Act. The estimates here include adults aged 19-64. The most recent Republican proposal from Representatives Bean and Hageman would apply work requirements to people aged 18-65, and many state proposals have included adults through age 64.^[36]

The estimates here are similar to previous estimates in that they do not include people enrolled through Medicaid disability pathways, as noted above. While we assume that states would automatically exempt these enrollees for the purpose of these estimates, the Limit, Save, Grow Act did not mandate their automatic exemption. Depending on the proposal and state implementation, it is possible that people enrolled through a Medicaid disability pathway, who numbered 9.2 million in fiscal year 2022, could be at risk.