A sweeping proposal in Congress could make millions of Americans ineligible for Medicaid by imposing new federal work requirements for the first time.
What’s in the bill?
The “One Big Beautiful Bill Act,” introduced by House and Senate Republicans, would require adults ages 19 to 64 to work or engage in approved activities for at least 80 hours each month to qualify for Medicaid. These rules would apply to enrollees in the Affordable Care Act expansion group as well.
Some exemptions would exist, including for adults with medical conditions or dependents. However, experts caution that these carve-outs may not fully protect eligible recipients from losing coverage.
How many people could be affected?
According to the Congressional Budget Office, the work requirements alone could leave 4.8 million more people uninsured by 2034. Combined with other changes in the legislation and the expiration of ACA tax credits, as many as 16 million people could lose health coverage.
What experts are saying
Health policy analysts say the proposed work rules could create new barriers to care.
“Exemptions don’t always work, and people could lose coverage anyway,” said Allison Orris, Medicaid policy director at the Center on Budget and Policy Priorities.
Robin Rudowitz, director of the Medicaid program at KFF, added that many current Medicaid recipients are already working, but new paperwork and verification could trigger disenrollments.
Senate vs. House versions
The Senate version of the bill introduces stricter provisions, limiting exemptions for parents to those with children under 15 years old. It also requires applicants to meet work requirements for at least one consecutive month before enrollment.
Eligibility reviews would occur at least twice a year, and the compliance look-back period would be capped at three months. Individuals denied Medicaid for not meeting work rules would also lose access to subsidized ACA coverage.
States would have until the end of 2026 to implement the requirements under the House version, while the Senate would extend that deadline to 2028 with a waiver.
Previous examples and cost impact
Arkansas previously implemented work requirements and saw a rise in uninsured residents without any notable increase in employment. Georgia is currently the only state with an active Medicaid work requirement, though several others have submitted federal waiver requests.
The House bill’s Medicaid work rules would reduce federal spending by $344 billion over 10 years, making it the legislation’s largest source of cost savings, according to KFF.
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