Medicaid Work Requirements In The One Big Beautiful Bill Act

The requirements apply to adults aged 19 to 64 enrolled in Medicaid through the Affordable Care Act (ACA) expansion: about 20 million Americans across 41 states and D.C. To stay eligible, enrollees must document 80 hours per month of employment, job training, education, community service or a combination of activities. States must verify compliance every six months.

Exemptions cover parents of children 13 and under, pregnant women, those deemed “medically frail,” people already subject to Supplemental Nutrition Assistance Program (SNAP) work requirements and federal disability recipients. The law also prohibits states from waiving the requirements through their standard Section 1115 demonstration authority, removing the flexibility states have historically used to adapt federal policy to local conditions.

The premise of work requirements is that Medicaid enrollees aren’t working and need an incentive to do so. However, a 2025 Urban Institute analysis found that more than nine in ten adults with Medicaid expansion coverage already work, are looking for work, attend school, care for family members, have a disability or are in poor health. Only about 2% cite lack of interest as a reason for not working. This is the group the law targets.

CBO estimates the provisions will cut federal Medicaid spending by $326 billion over ten years. This is the largest single source of savings in the law.

Lessons From Earlier Medicaid Work Requirement Programs In Arkansas and Georgia

Arkansas launched a work requirement in 2018, which was later struck down by courts in 2019. In the 18 months it operated, more than 18,000 people lost Medicaid coverage. In the end, it wasn’t because they weren’t working, but because they couldn’t navigate the reporting system. Online-only portals, confusing notices, and limited customer service excluded eligible enrollees. The program cost $26.1 million in administrative expenses without producing measurable employment gains.

Georgia’s Pathways to Coverage program launched in 2023 with similar results. By mid-2025, fewer than 7,500 individuals had enrolled out of an estimated 300,000 potentially eligible adults. The program cost more than $40 million in its first year, with nearly 80% going to administration rather than health care.

State-Level Implementation Challenges With Medicaid Work Requirements

Before work requirements are fully implemented, states face a complex set of operational decisions. They must build or adapt systems capable of verifying monthly compliance or exemptions, conduct more frequent eligibility redeterminations and define "medically frail" exemptions. They also must establish data-sharing processes to pull information from payroll systems, workforce agencies and educational institutions. Implementation will require extensive outreach, staff training and coordination.

The early-mover states offer a preview of how these programs may unfold. In Nebraska, key details are still being worked out just months before launch. At a January 2026 Medicaid Advisory Committee meeting, officials had not yet finalized how volunteer activities would be defined, how educational hours would be counted or how the state would operationalize the "medically frail" exemption. The state also will not increase staffing levels to manage the added workload, raising questions about administrative capacity.

Nebraska’s recent experience with eligibility redeterminations underscores how fragile enrollment systems can be even without added complexity. As of September 2025, more than half of Medicaid disenrollments during routine renewals were due to procedural reasons rather than confirmed ineligibility. This means that administrative barriers alone can drive substantial coverage loss among people who are actually eligible.

Montana has taken a different approach, emphasizing upfront investment in administrative capacity. The state plans to implement work requirements on July 1, 2026, and has announced plans to hire nearly 60 new staff at an estimated cost of $4.3 million per year. Officials have also confirmed a three-month transition period: people found noncompliant between July 1 and October 1 will receive informational notices rather than immediate disenrollment and will be referred to job services through the Department of Labor. What remains uncertain is how broadly exemptions including medically frail individuals will be applied.

What Medicaid Work Requirements Could Mean For The Health Of Americans

Medically vulnerable populations face disproportionate risk. Research on Arkansas’s program found that having a chronic condition was independently associated with higher Medicaid disenrollment rates. This means the people most likely to lose coverage are precisely those most likely to be harmed by losing it. Two-year follow-up research found disenrollment was associated with poorer medication adherence, delays in care and medical debt.

Research also consistently shows that gaining Medicaid coverage improves health. Medicaid expansion is linked with earlier cancer diagnoses, better chronic disease management, reduced medical debt, and lower mortality. Losing coverage will likely unwind these gains, interrupting treatment for diabetes, hypertension and heart disease, leading to delayed diagnoses and unfilled prescriptions.

Ultimately, how many Americans lose Medicaid coverage will depend on how states implement their programs. In particular, how they define medically frail, how user-friendly their reporting systems are, and how effectively they communicate with enrollees will shape outcomes. Montana and Nebraska have already demonstrated that there is more than one way to implement the same program. As the federal deadline for Medicaid work requirements approaches, every other expansion state will face the same choices — and the resulting consequences.