Why some Americans worry constantly about health insurance

Stephanie Ivory counts on Medicaid to get treated for gastrointestinal conditions and a bulging disc that makes standing or sitting for long periods painful. Her disabilities keep her from working, she said.

Ivory, 58, of Columbus, Ohio, believes she would be exempt from a requirement that adult Medicaid recipients work, but she worries about the reporting process. "It's hard enough just renewing Medicaid coverage every six months with the phone calls and paperwork," she said.

In Warrenton, Missouri, Denise Sommer hasn't worked in five years and relies on Medicaid to get care for anxiety, high blood pressure, and severe arthritis in her back and knees.

Sommer, 58, assumes she could easily qualify for an exemption with a doctor's note. "There's too much abuse in the system," she said. She added that she doesn't worry about others losing coverage for failing to meet reporting requirements.

"That's their own fault, because they should just keep their address updated with the state and read their mail," she said.

President Donald Trump's One Big Beautiful Bill Act, sprawling legislation to extend his tax cuts and enact much of his domestic agenda, would require 40 states and the District of Columbia, all of which expanded Medicaid, to add a work requirement to the program. Enrollees would have to regularly file paperwork proving that they are working, volunteering, or attending school at least 80 hours a month, or that they qualify for an exemption.

Many Republicans say nondisabled adults should not be on Medicaid, arguing the work requirement will incentivize more people to get jobs. House Speaker Mike Johnson has said it would help preserve Medicaid "for people who rightly deserve" coverage, "not for 29-year-old males sitting on their couches playing video games."

Last month, Johnson claimed 4.8 million Medicaid enrollees are choosing not to work, a figure disputed by health policy experts. Spokespeople for Johnson did not respond to a request for comment.

Studies by the Urban Institute and KFF show that, among working-age enrollees who do not receive federal disability benefits, more than 90% already work or are looking for work, or have a disability, go to school, or care for a family member and are unable to work.

Most Medicaid enrollees who are employed hold low-wage jobs, often with long or irregular hours and limited benefits, if any. Notably, their jobs often do not provide health insurance.

A new Urban Institute study found 2% of Medicaid expansion enrollees without dependents, about 300,000 people, report a lack of interest in working as the reason for not having employment.

The nonpartisan Congressional Budget Office estimates the work requirement in the House version of the legislation would lead to about 5 million adults losing Medicaid coverage by 2034; it has not yet analyzed the Senate bill. The Center for Budget and Policy Priorities, a left-leaning research organization, estimates that the Senate's version could cause as many as 380,000 more people to lose coverage.

According to the CBO, the work-requirement provision represents the largest cut to Medicaid in the House bill — about $300 billion over a decade, reflecting the savings from no longer covering millions of current enrollees.

The projected savings are telling, said Anthony Wright, executive director of Families USA, a consumer policy and advocacy organization. "That gives a sense of the order of its magnitude and harshness," he said.

Wright said that Republican-led states are likely to impose more burdensome reporting requirements. But even a less stringent approach, he said, will impose paperwork mandates that cause eligible beneficiaries to lose coverage.

Stephanie Carlton, chief of staff for the Centers for Medicare & Medicaid Services, said June 24 at Aspen Ideas: Health in Colorado that Trump administration officials believe the CBO is overstating the impact of the work requirement.

"We're making it easy" for people to report their work hours using technology, she said. She defended the proposed requirement as a way of better integrating Medicaid beneficiaries into their communities.

"We're a society, especially through covid, that disengaged from communities. We spend a lot of time online, on social media, and we lose that human-to-human interaction," Carlton said. "We're asking folks to engage in their communities. That's a fundamentally good thing to do that's part of getting benefits."

Under the GOP proposal, people would have to meet the new work requirements when they initially sign up for Medicaid, then report their work or exemption status at least every six months — and potentially as frequently as every month.

"This is not a conversation America should be in," said Leslie Dach, founder and chair of Protect Our Care, an advocacy group that supports the Affordable Care Act. "Think of real life. People are seasonal workers, or they work in retail, and it goes out of business or hours change. If you miss one month, you're kicked off."

The GOP legislation lists disability as an exemption, along with circumstances such as being incarcerated or being the parent of a dependent child. (The Senate bill, released on June 16, would exempt only the parents of children 14 and under.)

But even existing state and federal programs serving those with disabilities have different standards for determining eligibility.

Kevin Corinth, a senior fellow at the conservative American Enterprise Institute, said states may face challenges because many Medicaid enrollees with disabilities do not get Social Security Disability Insurance.

The federal government provides what's called Supplemental Security Income to those who meet certain thresholds for being low-income and disabled, and states are required to enroll SSI recipients in Medicaid.

But about two-thirds of adult enrollees who are under age 65 and disabled — that is, have difficulties with vision, hearing, mobility, or cognitive function, or in other areas — do not receive SSI, according to KFF.

"It's hard to know where to draw the line on who is disabled enough" to be exempt from the work requirement, Corinth said. "Some people will fall through the cracks, and states will have to do the best job they can."

He said states will be expected to rely on government databases, such as those maintained by their labor departments, to determine whether enrollees are working. But proving a disability could be more taxing for enrollees themselves, he said.

Two states that previously tried enacting Medicaid work requirements created strict rules for people with disabilities to get an exemption.

In Arkansas, the Medicaid work requirement had a 10-step online exemption process for individuals who were not automatically exempted by the state.

Consequently, although 30% of people subject to the requirement reported one or more serious health limitations, only 11% obtained a long-term exemption, according to the National Health Law Program.

Medicaid enrollees in Arkansas described a poorly functioning web-based reporting portal, inadequate outreach, and widespread confusion, according to focus-group interviews conducted by KFF.

Georgia's Medicaid work requirement also has presented challenges for people seeking an exemption based on a disability. They must request a "modification" from the state on its online portal, then wait for a phone call from the state to set up an interview to review the application. Then they must enroll in the state's job-training program before being allowed to sign up for Medicaid, according to the National Health Law Program.

Georgia has not disclosed how many people have applied for an exemption because of a disability or how many were approved.

Over 1 in 5 Medicaid enrollees have a disability, including 22% of those ages 19 to 49 and 43% of those 50 to 64, according to KFF.

Michael Karpman, principal research associate for the Urban Institute, said his group's findings — that only a small fraction of Medicaid enrollees are unemployed because they aren't interested in a job — explain why work-requirement programs in Arkansas and Georgia had no significant effect on employment even as they increased the number of uninsured adults.

"Many people fall off the Medicaid rolls due to red-tape reasons," he said, noting challenges requesting exemptions or reporting work. "People struggle with the documentation process."

Karpman said many people rely on Medicaid when they lose jobs that provide health coverage. The GOP work requirement, though, would deny them coverage while they're seeking new jobs.

Chris Bryant, a Medicaid enrollee in Lexington, Kentucky, has a bleeding disorder and lives in government housing on $1,100 per month in federal disability payments. He said adding a work requirement to Medicaid will only add barriers for people whose health issues prevent them from working. "It will be messy," he said.

Bryant, 39, said he knows people on Medicaid who could work but don't, though he surmises it's a small portion of the population. "People are on Medicaid because they have to have it and have no other option."