Medicaid Work Requirements in House Bill Spark Debate Over Coverage Impact

Republicans and Democrats have drawn battle lines over the potential effects of new Medicaid work requirements included in the recently passed House tax-and-spending legislation, with sharply contrasting claims about who would lose health coverage.

The House narrowly approved the One Big Beautiful Bill Act on May 22, which now moves to the Senate. According to the Congressional Budget Office (CBO), the legislation would result in 10.9 million more uninsured Americans by 2034, with 7.8 million of those losses coming specifically from Medicaid-related provisions.

House Speaker Mike Johnson and fellow Republicans have defended the bill, arguing it targets only those who shouldn’t have received coverage in the first place. “The numbers of Americans who are affected are those that are entwined in our work to eliminate fraud, waste and abuse,” Johnson said on CNN’s “State of the Union.”

Johnson has repeatedly claimed the legislation doesn’t actually cut Medicaid but instead strengthens it by reducing fraud. “There are no Medicaid cuts in the Big Beautiful Bill,” he insisted on NBC’s “Meet the Press.” “We’re reducing fraud, waste and abuse that is rampant in Medicaid to ensure that that program is essential for so many people.”

Health policy experts, however, paint a more complex picture. The nonpartisan Kaiser Family Foundation (KFF) estimates the bill would reduce federal Medicaid spending by $793 billion over ten years—a 12% reduction in federal funding.

The legislation’s central Medicaid provision would require adults who gained coverage under the Affordable Care Act’s Medicaid expansion to work, participate in community service, or engage in job training for at least 80 hours monthly. This group—approximately 21.3 million people across 40 states and Washington D.C.—would face these requirements unless they qualify for specific exemptions.

Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, explained that these work requirements effectively create paperwork hurdles. “It’s quite likely that there will be people… who have reported disabilities, who have other chronic conditions, and… who are caring for children or elderly parents, who may also lose coverage” because they can’t provide proper documentation.

The work requirement provision alone would cause 5.2 million people to lose Medicaid by 2034, with 4.8 million becoming completely uninsured, according to CBO estimates.

Democratic lawmakers have focused on the bill’s potential impact on vulnerable populations. Sen. Elizabeth Warren claimed that “every one” of Massachusetts’ approximately 2 million Medicaid enrollees “will be at risk of losing their health coverage.” KFF’s analysis suggests the state’s enrollment would actually drop by about 11% by 2034.

Leonardo Cuello of Georgetown University’s Center for Children and Families was more measured but still concerned: “Basically every type of Medicaid enrollee could be at risk of coverage loss.”

Republicans have specifically targeted what they describe as “able-bodied” adults choosing not to work. Rep. Tom Cole of Oklahoma said the bill “stops the subsidization of competent adults who are just choosing to not work.”

However, research suggests only a small percentage of Medicaid recipients fit that description. KFF analysis of Census Bureau data found that 64% of Medicaid recipients under 65 (and not receiving disability benefits) were already working full or part-time. Of the remainder, most weren’t working due to disability, illness, caregiving responsibilities, or being students. Only 8% weren’t working for other reasons, including retirement.

Previous state experiments with work requirements have highlighted implementation challenges. In Arkansas, over 18,000 adults were disenrolled in 2018 before a federal court halted the program. One man lost coverage when he was unaware he needed to file documentation monthly despite being employed at a poultry business.

Georgia’s program, which like the House bill requires proof of work before enrollment, has signed up just 7,400 people since July 2023—far below the 47,000 enrollees the state projected for the first two years.

Beyond work requirements, the bill includes other provisions affecting Medicaid coverage. It delays Biden-era rules that made it easier for seniors with Medicare to also enroll in Medicaid, potentially affecting 1.3 million people. The legislation also prohibits Medicaid payments to Planned Parenthood clinics for ten years and increases cost-sharing for certain Medicaid expansion enrollees.

Healthcare providers would also feel financial pressure under the legislation. Community health centers, which must provide care regardless of patients’ ability to pay, would face increased financial strain if more patients lose coverage. Rural hospitals, already financially vulnerable, could be further destabilized by the bill’s prohibition on states increasing provider taxes that help cover uncompensated care.

With approximately 19% of hospital care spending coming from Medicaid and roughly half of rural hospitals already operating with negative margins, the proposed funding reductions raise significant concerns about healthcare access, particularly in underserved communities.

As the legislation moves to the Senate, the debate continues over who would truly bear the brunt of these Medicaid changes—and whether the promised efficiency improvements justify the potential coverage losses for millions of Americans.