The Condition of Care: An In-Depth Analysis of Medicaid Work Requirements and Their Systemic Consequences

Executive Summary

The American health care safety net is undergoing a fundamental re-engineering.

With the passage of the “One Big Beautiful Bill” (OBBB) Act in 2025, the United States has mandated a nationwide policy of work requirements for certain Medicaid beneficiaries, transforming a cornerstone of the nation’s health insurance system from a needs-based entitlement into a conditional benefit.

This report provides an exhaustive analysis of this paradigm shift, examining its historical origins, the mechanics of the new federal law, the ideological underpinnings of the debate, and the extensive evidence from state-level experiments that foreshadow its national consequences.

The central finding of this analysis is unambiguous: Medicaid work requirements are a policy of intentional administrative failure.

Their primary, documented effect is not an increase in employment or economic self-sufficiency, but a significant loss of health insurance coverage driven by bureaucratic complexity.

Evidence from both government projections and real-world implementation demonstrates that these policies generate substantial federal savings by disenrolling millions of eligible individuals who are unable to navigate the labyrinthine reporting systems, not by moving them into jobs with private insurance.

The Congressional Budget Office (CBO) projects the new mandate will cause 5.2 million people to lose their Medicaid coverage while having a negligible effect on employment.¹

State-level experiments in Arkansas and Georgia serve as stark, predictive models of this dysfunction.

In Arkansas, the policy led to the disenrollment of over 18,000 people in less than a year, primarily due to confusion and an inaccessible online reporting portal.³

In Georgia, a similar program has been defined by exorbitant administrative costs—with over $86 million spent, mostly on consultants—and a catastrophic failure to enroll its target population, reaching less than 5% of those eligible due to a glitch-ridden system and overwhelming red tape.⁵

Personal narratives from these states reveal a human toll of lost care, worsening health, and economic ruin, directly contradicting the policy’s stated goals.

The burdens of this policy are not distributed equally.

They fall most heavily on the nation’s most vulnerable populations.

The “exemption paradox” ensures that the very individuals the law purports to protect—the medically frail, those with disabilities, and caregivers—are often the least equipped to handle the administrative hurdles required to prove their exempt status.

The policy disproportionately harms older adults, women, people with disabilities who fall into the “disability gap” between self-reported limitations and strict federal definitions, and residents of rural communities, where the loss of Medicaid revenue threatens the viability of local hospitals.⁷

Ultimately, this report concludes that Medicaid work requirements are predicated on a flawed understanding of both the Medicaid population—the vast majority of whom already work or face significant, unaddressed barriers to employment—and the precarious nature of the low-wage labor market.¹¹

The policy imposes rigid, monthly reporting demands that are fundamentally incompatible with the volatility of low-wage work.

The result is a costly, inefficient, and harmful system that functions not to promote work, but to ration health care through administrative attrition.

This analysis recommends a repeal of the federal mandate and a pivot toward evidence-based, voluntary supportive programs that address the true barriers to employment—such as lack of job training, childcare, and stable health coverage—rather than punishing individuals for systemic challenges beyond their control.

Section 1: The Great Re-Engineering: From Health Entitlement to Conditional Benefit

To comprehend the magnitude of the shift represented by a national Medicaid work requirement, one must first understand the program’s foundational principles and the evolutionary path that led to this turning point.

For over half a century, Medicaid operated as a health entitlement, its eligibility criteria rooted in financial need and categorical status.

The recent imposition of work as a condition of care represents not a minor tweak, but a radical departure from this original compact, a re-engineering of the program’s core identity.

This transformation was not sudden; it was the culmination of a decade-long policy debate catalyzed by the expansion of Medicaid under the Affordable Care Act and advanced through a series of state-level experiments that normalized a once-controversial idea.

1.1 The Original Compact: Medicaid’s Founding Purpose (1965-2010)

Medicaid was born in 1965 as Title XIX of the Social Security Act, a key pillar of President Lyndon B.

Johnson’s Great Society programs.¹³

It was established as a joint federal-state partnership with a clear and singular objective: to provide “Medical Assistance” to help states cover the health care costs for residents whose income and resources were insufficient to afford care.¹³

For the vast majority of its history, eligibility for Medicaid was not a universal entitlement for all low-income individuals.

Instead, it was tied to specific categorical groups that the law deemed particularly vulnerable: low-income families (primarily with dependent children), qualified pregnant women, children, individuals receiving Supplemental Security Income (SSI) due to age or disability, and seniors.⁴

The defining characteristic of this original compact was that eligibility was predicated on two factors: financial need (meeting specific income and, in some cases, asset tests) and non-financial criteria related to one’s status (such as age, pregnancy, disability, or parenting status).¹⁴

Critically, an individual’s employment status was not a factor.

The program was designed as a health care safety net, not a work program.

This foundational design persisted for decades, with various legislative expansions, such as the Omnibus Budget Reconciliation Act of 1990 which created the Medicaid Drug Rebate Program, broadening the program’s scope but not altering its fundamental, needs-based eligibility structure.¹³

1.2 The ACA Expansion and the Rise of Waiver-Based Experiments

The passage of the Patient Protection and Affordable Care Act (ACA) in 2010 marked the most significant change to Medicaid since its inception.¹³

The ACA fundamentally altered the eligibility landscape by allowing states to expand their programs to cover a new, large population: nearly all non-elderly adults with household incomes up to 138% of the federal poverty level (FPL).¹

This expansion was revolutionary because it untethered Medicaid eligibility from categorical status for this new group.

For the first time, a low-income adult could qualify for Medicaid based on income alone, regardless of whether they were a parent, pregnant, or had a disability.

This very expansion, however, inadvertently created the political and demographic predicate for the rise of work requirements.

By extending coverage to millions of so-called “able-bodied” adults without dependent children, the ACA created a target population against whom arguments for conditional eligibility could be more easily levied.¹⁵

This was compounded by the 2012 Supreme Court decision in

NFIB v.

Sebelius, which made the Medicaid expansion optional for states.¹³

This ruling created a political divide, with many Republican-led states initially refusing to expand.

In some of these non-expansion states, the idea of a partial expansion tied to conservative policy goals, like work requirements, began to gain traction as a politically palatable compromise.⁴

The vehicle for these policy experiments was Section 1115 of the Social Security Act.

These “demonstration waivers” allow the Secretary of Health and Human Services (HHS) to approve state-level pilot programs that test new approaches to Medicaid, provided they are “likely to assist in promoting the objectives” of the Medicaid program.¹⁵

The interpretation of this clause became a political battleground.

During the Obama administration, state requests to implement work requirements were consistently rejected on the grounds that they did not align with Medicaid’s core objective of providing health coverage.¹⁵

This policy was reversed under the first Trump administration.

In 2018, the Centers for Medicare & Medicaid Services (CMS) issued guidance actively inviting states to apply for 1115 waivers to test “community engagement” as a condition of eligibility, arguing that work could improve health outcomes.¹

This opened the floodgates, and between 2018 and 2020, CMS approved work requirement waivers for 13 states.¹⁵

However, these approvals were immediately met with legal challenges, and federal courts repeatedly struck them down, ruling that they were “arbitrary and capricious” because they undermined Medicaid’s primary purpose.⁴

The political pendulum swung again when the Biden administration took office in 2021 and systematically revoked the previously approved waivers, once again asserting that work requirements were inconsistent with the program’s objectives.¹

This volatile back-and-forth demonstrated the policy’s contested legal status and its dependence on the political orientation of the executive branch.

1.3 The “One Big Beautiful Bill” Act: Codifying a National Mandate

The cycle of administrative approvals and judicial reversals came to an abrupt end with the passage of the “One Big Beautiful Bill” (OBBB) Act, signed into law on July 4, 2025.¹⁹

This legislation represents the most profound re-engineering of Medicaid policy to date.

It takes the concept of work requirements out of the contested realm of 1115 waivers and codifies it as a mandatory, national feature of the program for the ACA expansion population.¹³

By amending the Social Security Act itself, the law effectively renders the previous legal debates moot.

The question is no longer whether work requirements “promote the objectives” of Medicaid; Congress has rewritten the rules to make them a required component.²⁰

This act mandates that by 2027, all states must condition Medicaid eligibility for this group on meeting monthly work or community engagement quotas.¹

This legislative history reveals a clear and strategic progression.

What began as a fringe, legally dubious state-level experiment was systematically normalized through persistent administrative action and political rhetoric.

The Trump administration’s willingness to approve waivers, despite a lack of evidence and strong legal opposition, created a new policy reality.

Even though courts invalidated these waivers, their temporary existence established a precedent and kept the issue at the forefront of the policy agenda.

The OBBB Act is the final step in this progression, cementing a contested administrative interpretation into durable federal law.

It demonstrates how a persistent political agenda can, over time, transform a controversial idea into a statutory mandate, bypassing judicial and empirical pushback.

The expansion of health coverage under the ACA, intended to broaden the safety net, paradoxically created the very conditions that allowed for a fundamental contraction of the program’s core principles.

Section 2: Anatomy of a Mandate: Deconstructing the 2025 Federal Work Requirement Law

The “One Big Beautiful Bill” Act establishes a complex and prescriptive federal framework that states will be required to implement.

Understanding the specific mechanics of this mandate—from the hourly requirements and target populations to the intricate web of exemptions and verification processes—is essential for analyzing its potential impact and the immense administrative challenges it poses for states and beneficiaries alike.

The law’s architecture contains several design features that, while seemingly protective, create profound structural barriers to coverage.

2.1 The 80-Hour Rule: Defining “Community Engagement”

At the heart of the new federal law is a rigid monthly quota.

To maintain eligibility, affected Medicaid beneficiaries must document at least 80 hours per month of participation in qualifying “community engagement” activities.¹

The law provides a specific list of activities that can be used to meet this threshold:

• Employment: Working in a traditional job for pay.
• Work Programs: Participating in job skills training, vocational education, or similar programs.
• Education: Enrolling at least half-time in a secondary school, college, or university.
• Community Service: Performing unpaid volunteer work for a charitable or religious organization.
• Combination of Activities: Beneficiaries can combine hours from any of the above activities to reach the 80-hour monthly total.¹⁵

This 80-hour-per-month standard, equivalent to 20 hours per week, has been a common feature in most state-level waiver proposals over the years.⁴

Its codification into federal law establishes a uniform, national benchmark for what constitutes sufficient community engagement.

2.2 Populations Subject to the Mandate and the Web of Exemptions

The mandate is not applied to all Medicaid beneficiaries.

It is narrowly targeted at a specific segment of the population: adults aged 19 to 64 who are covered under the ACA’s Medicaid expansion or through similar Section 1115 demonstration waivers that provide minimum essential coverage, such as those in Georgia and Wisconsin.¹

This means that traditional Medicaid populations—including children, pregnant women (through their postpartum period), seniors over 65, and most individuals who qualify for Medicaid through a formal disability determination (i.e., receiving SSI)—are not subject to the requirement.

The law also specifies a long list of mandatory exemptions for individuals within the target population who are not expected to work.

These exemptions are critical, as they are intended to shield the most vulnerable from losing coverage.

Key exempted groups include:

• Individuals who are pregnant or in their postpartum recovery period.³
• Parents or caretakers who are responsible for a dependent child under the age of 13.³
• Individuals who are deemed “medically frail.” This is a broad category that can include people who are blind or have a disability, a substance use disorder, a disabling mental disorder, a physical, intellectual, or developmental disability, or a serious or complex medical condition.³
• Former foster youth under the age of 26.¹⁹
• Individuals recognized as American Indians or Alaska Natives who are eligible for services through the Indian Health Service.¹⁹
• Individuals facing certain short-term hardships, which states may define to include circumstances like hospitalization, residing in a federally declared disaster area, or living in a county with high unemployment.¹⁹

While this list of exemptions appears comprehensive, it creates a significant paradox.

The very conditions that qualify an individual for an exemption—such as a serious medical condition or a disabling mental disorder—are often the same barriers that prevent them from successfully navigating the complex bureaucratic process required to prove their exempt status.²

The burden of proof falls on the beneficiary to gather documentation, complete forms, and meet reporting deadlines.

Evidence from past state experiments demonstrates that many people who should have been exempt lost coverage precisely because of these administrative hurdles.²¹

In New Hampshire’s brief experiment, for example, the state received far fewer requests for a medical frailty exemption than the number of individuals who had previously self-attested to having such a condition, highlighting a massive gap between eligibility for an exemption and the ability to secure one.¹⁰

This reveals a critical design flaw: the policy’s mechanism for protecting the vulnerable simultaneously creates a new barrier that disproportionately harms the very people it is intended to help.

2.3 Verification, Reporting, and the “Look-Back” Period

The law imposes a significant verification and reporting burden on both states and beneficiaries.

States are required to verify an individual’s compliance with the work requirement (or their exempt status) at two key junctures: at the time of their initial application and at each subsequent eligibility redetermination.³

The law also permits states to require verification more frequently, potentially as often as every six months.³

A particularly consequential provision is the “look-back” period.

For new applicants, states must verify that they met the 80-hour requirement for a period of between one and three months before their application can be approved.¹⁹

For current enrollees, states must verify compliance for at least one month within each six-month eligibility review period.¹⁹

The law encourages states to use automated data matching with sources like state payroll data “where possible,” but it does not mandate or provide dedicated funding for the development of these highly complex IT systems.³

The consequence for failing to meet these requirements is severe: termination of Medicaid coverage.¹

The look-back period for new applicants creates a particularly pernicious hurdle, functioning as a “pre-denial” mechanism.

People typically seek Medicaid after a negative life event, most commonly a job loss.²⁴

Under this rule, a person who has just been laid off will, by definition, be unable to document 80 hours of work in the preceding month.

This creates a mandatory waiting period during which a newly unemployed and uninsured individual must find a new job, work for at least a month, and secure the necessary documentation before they can even successfully apply for health coverage.

This fundamentally changes Medicaid from a safety net that catches people when they fall into a system that is inaccessible precisely when it is most needed.

2.4 The Federal Implementation Timeline and State Discretion

The federal government has established a clear, albeit aggressive, timeline for national implementation.

The key milestones are as follows:

• June 1, 2026: The Secretary of HHS is required to release an interim final rule to guide state implementation. Notably, the law specifies that this rule will not be subject to the standard public notice and comment period, limiting stakeholder input.³
• September 30, 2026: States must begin outreach efforts to inform Medicaid beneficiaries about the new requirements.³
• January 1, 2027: This is the mandatory date by which all states must have their work requirement programs in effect.¹

Despite the federal mandate, states retain some discretion.

A state can choose to implement its program earlier than 2027 by seeking a Section 1115 waiver.¹⁹

Conversely, states can request an extension of the deadline up to December 31, 2028, but only if they can demonstrate to the HHS Secretary that they are making a “good faith effort to comply” with the new rules.¹

This flexibility acknowledges the immense administrative lift required but ultimately keeps all states on a path toward implementation.

Section 3: The Ideological Fault Line: Competing Visions for America’s Health Safety Net

The debate over Medicaid work requirements is more than a simple disagreement over policy mechanics; it is a manifestation of a deep and enduring ideological fault line in American politics.

At its core, the conflict is animated by two fundamentally different visions of Medicaid’s purpose and its role in society.

Proponents view it through the lens of welfare and personal responsibility, arguing that conditioning benefits on work promotes self-sufficiency.

Opponents see it as a health insurance program, arguing that providing stable health care is a prerequisite for economic participation.

Understanding these competing philosophies is crucial to deciphering why the debate is so polarized and why the two sides often seem to be speaking different languages.

3.1 The Proponent’s Case: Work as a Pathway to Health and Self-Sufficiency

Proponents of work requirements consistently frame the policy not as a punitive measure, but as a tool for “community engagement” designed to benefit the enrollee.

The stated rationale is that work is intrinsically linked to health and well-being, and that by encouraging employment, the policy will lead to better health outcomes, greater financial independence, and an eventual transition off government assistance.²

This perspective is often articulated with language suggesting that the policy is necessary to address concerns about dependency, with claims that “individuals are sitting on the sidelines” of the economy.²

The argument extends to the idea that Medicaid’s traditional structure, based solely on income, creates a disincentive to work.

Proponents contend that income limits can create a “benefits cliff” where earning slightly more money could cause an individual to lose their health coverage, thereby discouraging them from seeking higher-paying jobs or more hours.²⁵

From this viewpoint, a work requirement is a necessary corrective to align the incentives of the program with the values of work and self-reliance.

In states like Arkansas, the policy was also justified as a way to address perceived social tensions in low-income communities between those eligible for free health insurance and those who were not, making the program more politically palatable to taxpayers.¹⁷

3.2 The Opponent’s Rebuttal: Evidence, Legality, and the Purpose of Medicaid

Opponents counter these arguments with a barrage of evidence from decades of research on safety-net programs and the specific, disastrous results of state-level Medicaid experiments.

Their rebuttal rests on three pillars: the policy is ineffective, unnecessary, and harmful.

• Ineffectiveness: Critics point to overwhelming evidence that work requirements do not achieve their stated goal of boosting employment. The non-partisan Congressional Budget Office (CBO) has repeatedly concluded that such policies would have a “negligible effect on employment status or hours worked”.² Research on similar requirements in other programs, like the Temporary Assistance for Needy Families (TANF) program, found they had little to no long-term effect on increasing work or reducing poverty; in fact, some participants became poorer.²⁶
• Unnecessariness: A core counterargument is that the policy is a solution in search of a problem. Data consistently shows that the vast majority of adult Medicaid beneficiaries who are able to work already do.³ A 2023 KFF analysis found that 64% of Medicaid adults were working full or part-time. Of those not working, the overwhelming majority cited reasons that would likely qualify them for an exemption under the new law, such as caregiving responsibilities (12%), illness or disability (10%), or attending school (7%). Only a tiny fraction (8%) were not working for other reasons, such as an inability to find a job.⁵
• Harmfulness: The most forceful critique is that the policy’s primary and predictable outcome is the loss of health insurance for large numbers of people. This loss of coverage leads to demonstrably worse health outcomes, as people delay necessary care, ration medications, and accumulate medical debt.²⁶ This, in turn, makes it
  harder for them to maintain employment, creating a vicious cycle that directly contradicts the policy’s purported aims.

Before the OBBB Act rewrote the statute, opponents also mounted successful legal challenges, arguing that work requirements were illegal under the Social Security Act.

Federal courts consistently agreed, ruling that the core objective of Medicaid is to furnish medical assistance, and that policies which result in widespread coverage loss are fundamentally at odds with that purpose.¹⁸

3.3 Beyond the Talking Points: Is Medicaid Welfare or Health Insurance?

The intractability of this debate stems from a fundamental disagreement about what Medicaid is.

This philosophical divide explains why evidence of policy failure does little to dissuade proponents.

For many conservatives, Medicaid—especially the ACA expansion population—is viewed as a form of welfare, analogous to cash assistance programs like the old Aid to Families with Dependent Children (AFDC).²⁸

From this perspective, it is a program that can foster dependency and should therefore be coupled with “reciprocal obligations” like work requirements.

The goal is not just to provide a service, but to shape behavior and enforce societal norms around work.

Making it tougher to get benefits is seen as a feature, not a bug, as it reinforces the principle of personal responsibility.²⁸

For liberals and most of the public health community, Medicaid is seen as a health insurance program, a vital component of the social safety net akin to Medicare for seniors.²⁸

The view is that providing stable health coverage is a public good that creates the foundation for economic stability and participation.

If people are healthy, they are far more likely to be able to find and keep a job.

From this viewpoint, taking away health care as a punishment for not working is counterproductive and cruel, as it removes the very tool that enables many to work in the first place.²⁸

This schism in framing—”welfare” versus “insurance”—is the ideological engine driving the entire conflict.

It also exposes a critical flaw in the proponents’ logic.

Unlike the welfare reform efforts of the 1990s, which at least rhetorically were based on a “reciprocal obligation” where government provided support services, the Medicaid work requirement is a “one-way street”.²⁸

The OBBB Act and the state waivers that preceded it impose a strict obligation on the beneficiary without a corresponding federal investment in the tools needed for success, such as job training, childcare subsidies, or transportation assistance.⁴

This reveals the policy’s primary function is not to enable work in a supportive manner, but to enforce a condition for coverage, regardless of the structural barriers an individual may face.

The policy’s design actively inverts causality: by removing health coverage from those who fail to meet the work rule, it makes them less healthy, and thus less able to work, serving as a grim real-world experiment that validates the opponents’ core argument.

Section 4: The Human Ledger: Quantifying the Impact on Coverage, Employment, and Health

Beyond the ideological debate, a substantial body of quantitative analysis from non-partisan government sources and independent research institutions provides a clear and sobering forecast of the national work requirement’s impact.

These projections, largely informed by the real-world outcomes of state-level experiments, paint a consistent picture: the policy is expected to cause millions to lose health coverage and become uninsured, all while failing to achieve its stated goal of increasing employment.

The federal savings generated by the policy are a direct result of this coverage loss, representing a cost shift to individuals, providers, and states, rather than a true efficiency.

4.1 CBO Projections: The Scale of Coverage Loss and Federal Savings

The Congressional Budget Office (CBO), the official scorekeeper for federal legislation, has provided the most authoritative projections on the effects of the OBBB Act’s work requirement mandate.

The headline figures are stark:

• Massive Coverage Loss: The CBO projects that approximately 5.2 million people will lose their Medicaid coverage as a direct result of the work requirement policy.¹
• Increase in the Uninsured: The vast majority of these individuals are expected to become uninsured after losing Medicaid.¹ Earlier CBO analyses of similar but less expansive proposals estimated that work requirements would cause the largest single increase in the number of people without health insurance, with one estimate projecting 4.8 million newly uninsured.³
• Significant Federal Savings: The policy is projected to reduce federal Medicaid spending by $326 billion over a ten-year period.³ This accounts for the largest share of the OBBB Act’s total Medicaid cuts of $911 billion.³

These figures reveal the policy’s core fiscal logic.

The substantial federal savings are not an ancillary benefit but a primary driver of the policy, often promoted as a way to offset the cost of other legislative priorities, such as tax cuts.³

4.2 The Employment Myth: Why Work Requirements Don’t Increase Work

Perhaps the most critical finding from the CBO and other independent analyses is that the policy is not expected to work as advertised.

The CBO has stated that the work requirement will have a “negligible effect on employment status or hours worked by people who would be subject to the work requirements”.²

This conclusion is echoed in research examining the Arkansas experiment, which found no significant change in employment among the target population after the policy was implemented.⁹

The reason for this lack of impact is straightforward: the policy is based on a false premise.

As detailed previously, the overwhelming majority of Medicaid beneficiaries subject to the rules are either already working or face substantial, well-documented barriers to employment that the policy does nothing to address.²¹

These barriers include chronic illness, a disability that doesn’t meet the strict federal definition, significant caregiving responsibilities, lack of affordable transportation or childcare, or a scarcity of available jobs in their community.²¹

For the small fraction of enrollees who are not working and do not have an obvious exemption, simply taking away their health insurance provides no new tools or opportunities to overcome these structural obstacles.

This combination of CBO findings—that millions will lose coverage while employment rates remain unchanged—is a quantitative confirmation that the policy’s primary mechanism is administrative failure, not behavioral change.

The $326 billion in federal savings is generated by people failing to navigate the bureaucracy, not by people getting jobs and earning their way off the program.

The data implicitly validates the core critique that the policy is designed to “trip people up” and “saves” money by making it difficult for eligible people to retain the coverage to which they are legally entitled.²⁷

4.3 Health and Economic Consequences of Disenrollment

The loss of health coverage is not merely a statistical event; it has profound and devastating consequences for the health and financial stability of individuals and families.

The brief but damaging experiment in Arkansas provides a real-world preview of what can be expected on a national scale.

Studies of those who lost coverage in Arkansas found that they:

• Delayed or Forwent Medical Care: Individuals reported delaying needed medical care and skipping doctor’s visits due to cost after losing their insurance.²⁷
• Struggled to Afford Medications: Many were unable to afford their prescription drugs, leading them to ration or go without essential medicines for chronic conditions like COPD and diabetes.¹⁷
• Incurred Significant Medical Debt: Seeking necessary care in emergency rooms without insurance led to crippling medical debt, with some individuals facing thousands of dollars in hospital bills.¹⁷

Polling from KFF reinforces the gravity of these consequences.

When working Medicaid enrollees were asked about the potential impact of losing their coverage, the responses were overwhelming: 92% said it would have an impact on their physical health and quality of life, 91% on their financial health, and 80% on their mental health.³⁰

Nearly nine in ten said it would be difficult to afford their prescription medications, and eight in ten said it would be difficult to get and pay for another form of health insurance.³⁰

These findings expose the fallacy of the federal “savings.” The $326 billion is not eliminated from the system; it is transferred.

The costs are shifted directly onto individuals in the form of out-of-pocket expenses and medical debt; onto health care providers, especially rural and safety-net hospitals, in the form of uncompensated care for emergency services; and onto state and local governments that must deal with the downstream effects of a sicker, less financially stable population.⁹

From a systemic perspective, the federal saving is an accounting illusion that likely leads to higher overall health care costs in the long run by replacing efficient preventive and primary care with inefficient and expensive emergency care.

Section 5: Laboratories of Bureaucracy: Lessons from the Front Lines in Arkansas and Georgia

The national debate over Medicaid work requirements is not a purely theoretical exercise.

Two states, Arkansas and Georgia, have served as real-world laboratories for this policy, providing a wealth of empirical data and human stories that are not just historical case studies but predictive models for the challenges of national implementation.

Their experiences demonstrate, with remarkable consistency, that the policy’s stated goals are eclipsed by its operational failures.

The primary outcome in both states has been driven not by the work rule itself, but by the massive, dysfunctional administrative apparatus created to enforce it.

These case studies prove that in a system of conditional benefits, the design and execution of the bureaucracy is the policy.

5.1 Case Study: The Arkansas Experiment (2018-2019)

Anatomy of a Collapse: In June 2018, Arkansas became the first state in the nation to implement a Medicaid work requirement, mandating that ACA expansion enrollees aged 19-49 report 80 hours of work or community engagement activities each month.⁴

The experiment was short-lived; a federal judge halted the program in March 2019, ruling it was inconsistent with Medicaid’s objectives.¹⁷

But in the nine months it was active, the policy caused a catastrophic loss of coverage.

More than 18,000 people—representing nearly one-third of all beneficiaries subject to the rules—were disenrolled.³

The Central Role of Administrative Failure: Overwhelming evidence from researchers, state officials, and enrollees themselves shows that this mass disenrollment was not due to a widespread refusal or inability to work.

Instead, it was the direct result of a confusing and inaccessible administrative system.¹⁷

The key flaws included:

• An Online-Only Reporting Portal: Beneficiaries were required to report their hours monthly through a state-run website.⁴ This created an insurmountable barrier for the many low-income Arkansans who lacked reliable internet access, a computer, or the digital literacy needed to navigate the system.¹⁸
• Widespread Confusion and Lack of Awareness: Despite what some officials described as “robust” state outreach efforts, a stunning number of beneficiaries were either completely unaware of the new requirement or did not understand that it applied to them.¹⁷ Many described the official notices as long and confusing.³² A common and tragic pattern emerged: enrollees often discovered they had lost their health insurance only when they were turned away at a pharmacy or a doctor’s office.¹⁸

Personal Narratives of Hardship: The data on coverage loss is brought into sharp relief by the personal stories of those affected.

These narratives transform abstract statistics into a ledger of human suffering and illustrate the policy’s perverse, real-world consequences.

• Adrian McGonigal: Mr. McGonigal’s story is a perfect microcosm of the system’s failure. He worked full-time at a chicken processing plant and dutifully reported his hours when the program began. However, he misunderstood the rules and believed he only needed to report once.³³ Months later, he was shocked to learn at a pharmacy that his coverage had been terminated. Unable to afford his $800 breathing treatments for COPD, his health rapidly deteriorated, leading to emergency room visits and, eventually, the loss of his job due to illness. He ultimately ended up on disability. An attorney who helped him noted, “The work requirements are the clear point that sent his life on a downward spiral that he never recovered from”.²⁹
• Charles Gresham: A 37-year-old man with a seizure disorder, Mr. Gresham had worked most of his life but struggled to maintain steady employment due to his medical condition. His story highlights the impossible situation for individuals with health issues that are serious enough to impede work but do not meet the strict criteria for a formal disability exemption, leaving them caught in the policy’s net.²⁹

5.2 Case Study: Georgia’s Pathways to Coverage (2023-Present)

An Expensive Failure: Learning little from Arkansas’s collapse, Georgia launched its own work requirement program, “Pathways to Coverage,” in July 2023.

It offers limited Medicaid coverage to adults with incomes up to 100% of the FPL, but only if they can prove 80 hours of monthly work or other qualifying activities.¹

The results have been an unmitigated disaster, characterized by staggering inefficiency and a failure to achieve any of its goals.

• Massive Enrollment Shortfall: The state projected it would enroll 25,000 people in the first year.⁶ After 18 months, only about 6,500 to 7,500 people had successfully enrolled—a failure rate of stunning proportions, reaching less than 5% of the estimated 175,000 eligible Georgians.⁶
• Exorbitant Administrative Costs: The program has been a fiscal black hole. As of late 2024, Georgia had spent over $86.9 million in state and federal funds on Pathways.⁶ An analysis by ProPublica found that the vast majority of this spending—more than 75%—went not to providing health care, but to consultants (including over $50 million to Deloitte for the IT system) and administrative overhead.⁵

“A Nightmare of Red Tape”: The reason for this failure is, once again, a bureaucracy seemingly designed to thwart enrollment.

A deep-dive investigation by ProPublica and other outlets documented a litany of administrative barriers:

• A Glitchy, Unusable Portal: The online application portal, built by Deloitte, was plagued by technical glitches, frequently crashing, freezing, and erasing applicants’ personal information, forcing them to start over repeatedly.⁶
• Application Backlogs and Abandonment: The dysfunctional system led to a massive backlog of 16,000 unprocessed applications. In some months, more than 40% of people who started an application simply gave up in frustration.⁶
• Overwhelmed State Agencies: The Georgia Division of Family and Children Services (DFCS), already suffering from high staff turnover and swamped with other work, was tasked with verifying eligibility for Pathways without a significant increase in resources, leading to massive delays.⁶
• Implicit Admission of Failure: In a quiet but telling move, the state administration, which had heralded monthly work verification as a core tenet, rolled back the requirement. It now only verifies work status at initial enrollment and annual renewal, an implicit acknowledgment that the monthly reporting system was unworkable.⁶

The Faces of Frustration: The stories from Georgia underscore that even the most capable individuals can be defeated by a sufficiently broken system.

• Tanisha Corporal: A licensed master social worker, Ms. Corporal was an expert in navigating social service systems. Yet, it took her eight months of relentless effort—fighting inexplicable denials, resubmitting documents that disappeared into the portal, and appealing decisions—to get herself and her college-student son approved. “I did everything right,” she said, “And we were denied.” Her case was only resolved after she spoke out at a public hearing covered by the media.³⁴ This “expert-proof” system failure demonstrates that the problem is not user error but profound systemic dysfunction.
• Luke Seaborn: In a story of stunning irony, Mr. Seaborn was featured in Governor Kemp’s own promotional video lauding the Pathways program. A small business owner, he was initially grateful for the coverage. But in the months that followed, he had his benefits canceled twice due to what he described as bureaucratic red tape and technical glitches, despite his efforts to comply. His verdict became a powerful indictment of the program’s reality: “I used to think of Pathways as a blessing. Now, I’m done with it”.³⁵
• Paul Mikell: A truck driver and electrician who works part-time in exchange for housing, Mr. Mikell’s story highlights the system’s disconnect from the reality of the low-wage economy. Lacking traditional pay stubs, he faced immense difficulty providing the documentation required for verification, a common problem for the millions of Americans working in the informal or gig economy.⁶

These two state-level disasters offer indelible lessons.

They show that regardless of the specific design—whether the failure point is reporting (Arkansas) or application (Georgia)—these policies are defined by their administrative complexity, their high costs, and their devastating human consequences.

Metric	Arkansas (“Arkansas Works”)	Georgia (“Pathways to Coverage”)
Implementation Period	June 2018 – March 2019	July 2023 – Present
Target Population	ACA Expansion Adults, Ages 19-49	Adults up to 100% FPL, Ages 19-64
Primary Outcome	Mass Disenrollment	Mass Non-Enrollment
Documented Impact	Over 18,000 individuals lost coverage in <1 year (~30% of those subject to the rule).3	Fewer than 7,500 enrolled out of 175,000+ eligible after 18 months (<5% enrollment rate).6
Key Administrative Flaw	Confusing, online-only reporting portal inaccessible to many; widespread lack of awareness.4	Glitchy, dysfunctional application portal; massive backlogs; understaffed state agencies.6
Documented Cost	High administrative burden cited, but specific dollar amount not available in provided materials.17	Over $86.9 million spent, with more than 75% going to administration and consultants, not health care.5
Key Personal Narrative	Adrian McGonigal: A full-time worker who lost coverage due to a reporting misunderstanding, leading to worsened health and job loss.29	Tanisha Corporal / Luke Seaborn: A social work expert who fought for 8 months to enroll; the program’s promotional face who was later kicked off twice.34

Section 6: The Vulnerability Cascade: Disproportionate Impacts on At-Risk Populations

While Medicaid work requirements pose a threat to all beneficiaries in the target population, their burdens are not distributed evenly.

The policy’s rigid structure and administrative complexity create a “vulnerability cascade,” where the negative impacts fall most heavily on specific, already-marginalized groups.

The system’s design disproportionately penalizes individuals with disabilities, older adults, women serving as caregivers, and residents of rural areas.

Furthermore, the consequences ripple outward, creating an intergenerational transfer of harm as children lose coverage when their parents are caught in bureaucratic traps.

6.1 The Disability Gap: When Self-Reported Disability Meets a Narrow Federal Definition

The federal mandate includes an exemption for individuals with disabilities, but this protection is dangerously narrow.

The law relies on the strict, work-focused definition of disability used by the Supplemental Security Income (SSI) program, which requires an individual to have a significantly impaired ability to work.¹⁰

This creates a vast “disability gap.” A large segment of the Medicaid population suffers from chronic health conditions or functional limitations that seriously impede their ability to work consistently, yet they do not meet the stringent criteria for an SSI-based disability determination.¹⁰

The data reveals the scale of this gap.

While only about 10% of Medicaid beneficiaries qualify for the program through a formal disability-related pathway, national surveys show that 33.9% of enrollees self-report having a disability.¹⁰

This means that millions of people with significant health challenges are not automatically exempt and are therefore subject to the work requirement.

Research confirms a powerful link between chronic disease and reduced workforce participation; one study found that older Medicaid beneficiaries with multiple chronic conditions had dramatically higher odds of working fewer than 20 hours per week.³⁷

For these individuals, the policy creates an impossible Catch-22: the very health coverage that enables them to manage their conditions and participate in the workforce is threatened if their health conditions prevent them from meeting a rigid monthly work quota.

6.2 Older Adults (50-64): Caught Between Chronic Illness and the Workforce

Adults in the 50-to-64 age bracket are at a particularly high risk of losing coverage under the new mandate.

Analysis by KFF shows this group is less likely than younger adults to be working 80 or more hours per month and also less likely to qualify for an obvious exemption like being in school or caring for a young child.⁷

Nearly three in ten Medicaid adults in this age group do not meet the work requirement and do not appear to qualify for an exemption.⁷

This population faces a dual challenge.

On one hand, they often encounter age discrimination in the labor market, making it harder to find and maintain employment.

On the other, they have a higher prevalence of chronic health conditions that may not be severe enough to qualify them as “medically frail” but are substantial enough to make consistent, full-time work difficult.²

A study focusing on this age group found that two-thirds of participants worked fewer than 20 hours per week, putting the majority at risk of losing coverage under the new rules.³⁷

The health consequences of losing Medicaid can be especially severe for older adults, and the economic consequences potentially devastating.²

6.3 Women and Caregivers: Penalizing Unpaid Labor

The work requirement policy has a distinctly gendered impact.

Women constitute over half of all adult Medicaid enrollees.⁸

They are also far more likely than men to be performing the essential, unpaid labor of caregiving.

According to KFF data, 19% of non-working women on Medicaid cite caregiving as their primary reason for not being in the workforce, compared to just 4% of men.⁸

While the law provides an exemption for parents of children under 13, this fails to capture the full scope of caregiving responsibilities that fall disproportionately on women.

Many are caring for aging parents, spouses with chronic illnesses, or adult children with disabilities—labor that is crucial to family well-being and often prevents them from holding a traditional job.⁸

Even among women without children, over one in ten report not working due to caregiving duties.⁸

By failing to adequately recognize and exempt this vital unpaid work, the policy effectively penalizes women for fulfilling traditional caregiving roles.

6.4 The Churn Effect on Young Adults and Rural Communities

Young adults (ages 19-27) also face unique vulnerabilities.

While they have high rates of work and school attendance, their lives are often characterized by instability.

Research shows they are more likely than older adults to move frequently, which puts them at risk of not receiving renewal notices sent to old addresses.²³

They also tend to have more volatile employment and educational situations and struggle more with navigating complex bureaucracies.

The law’s requirement for eligibility checks as often as every six months is likely to hit this population particularly hard, leading to coverage loss due to administrative “churn” rather than a change in eligibility.²³

The impact on rural communities is systemic.

Rural areas have higher rates of disability and a greater reliance on Medicaid for health coverage.⁹

The financial health of rural hospitals is deeply intertwined with Medicaid reimbursement rates.

These hospitals already operate on razor-thin margins, with 44% operating at a loss in 2023.⁹

The mass loss of coverage and the corresponding reduction in federal Medicaid funds projected under the work requirement will place hundreds of these critical institutions at immediate risk of closure.

The closure of a rural hospital is a devastating blow to a community, eliminating not only a primary source of health care but also a major local employer, with negative consequences for everyone in the area, not just Medicaid beneficiaries.⁹

6.5 The Unintended Consequence: How Children Lose Coverage When Their Parents Do

One of the most tragic and entirely predictable consequences of imposing work requirements on adults is the “spillover” effect on their children.

Decades of research have documented the “welcome mat” effect: when parents gain Medicaid coverage, their eligible children are significantly more likely to be enrolled and to receive consistent care.

The inverse is also true: when parents lose coverage, their children are at high risk of losing it as well, even if the children themselves remain fully eligible.²²

This occurs for several reasons.

A parent who is disenrolled may mistakenly believe the entire family has lost coverage.

They may no longer interact with the state agency, missing important renewal notices for their children.

The administrative barriers that cause a parent to lose coverage can inadvertently lead to their children being dropped from the rolls during eligibility redeterminations.

Projections estimate that work requirements applied only to expansion-group adults could cause 480,000 children to lose their health insurance; if applied more broadly, that number could rise to over 900,000.²²

This demonstrates how the policy’s impact is not contained to the individual enrollee.

It creates a cascade of harm that is transferred from one generation to the next, undermining child health and well-being and contradicting fundamental public health goals.

Section 7: The Unseen Engine of Disenrollment: Administrative Complexity and the Low-Wage Reality

The accumulated evidence from state experiments, non-partisan analysis, and academic research converges on a single, powerful thesis: the catastrophic coverage losses caused by Medicaid work requirements are not primarily a function of the work rule itself.

Instead, they are the product of the massive, complex, and unforgiving administrative apparatus constructed to enforce it.

This bureaucracy, often described as a “morass of paperwork” and “red tape,” functions as the true engine of disenrollment.²⁷

Its rigid, monthly demands are fundamentally incompatible with the precarious and volatile reality of the American low-wage labor market, creating a system that punishes workers for the inherent instability of their jobs.

7.1 The Primacy of “Red Tape”: How Bureaucratic Hurdles Drive Coverage Loss

The core finding from every real-world implementation of Medicaid work requirements is that people lose coverage not because they aren’t working, but because they cannot successfully navigate the process to prove that they are.²⁷

Critics have aptly described the policy as a “wolf in sheep’s clothing”—a measure that sounds reasonable but in practice is “designed to trip people up”.²⁷

The experiences in Arkansas and Georgia are the definitive proof.

In Arkansas, the 18,000 coverage losses were overwhelmingly attributed to confusion about the rules and an inability to use the online reporting system.³¹

In Georgia, the near-total failure of the program to enroll eligible individuals was a direct result of administrative barriers like a malfunctioning website and overwhelming paperwork demands.³¹

This outcome is not an accident; it is a predictable feature of the policy’s design.

By layering complex new reporting and verification requirements onto an already-strained system, the policy erects new hurdles that many eligible individuals, particularly the most vulnerable, are unable to clear.

The result is that the administrative process itself, rather than an individual’s work status, becomes the primary determinant of whether they can maintain their health insurance.

Work Status & Barriers to Work Among Medicaid Adults, 2023
Working Full-Time	44%
Working Part-Time	20%
Not Working Due to Caregiving	12%
Not Working Due to Illness or Disability	10%
Not Working Due to School Attendance	7%
Not Working (Other Reasons, e.g., inability to find work)	8%
Source: KFF analysis of 2023 data.11

As the data in the table above illustrates, the foundational premise of the policy—that a large population of “able-bodied” adults are choosing not to work—is false.

Nearly two-thirds (64%) of Medicaid adults are already working.

The vast majority of the remainder are either caregivers, ill or disabled, or in school.

The policy’s complex administrative machinery is thus brought to bear on a population for whom it is largely irrelevant, putting the coverage of millions at risk to target a problem that barely exists.

7.2 The Mismatch: The Reality of Unstable, Low-Wage Work vs. Rigid Monthly Reporting

The administrative failure of work requirements is magnified by a fundamental mismatch between the policy’s rigid structure and the fluid, often precarious, nature of low-wage work in the 21st-century economy.

The law’s demand for a consistent 80 hours of documented work every single month is profoundly out of touch with the reality faced by millions of Americans in the service, retail, and gig economies.²⁴

The low-wage labor market is defined by instability, much of which is driven by employers, not employees:

• Volatility of Hours: Many employers utilize “just-in-time” scheduling practices, using software to adjust staffing levels based on minute-to-minute consumer demand. This results in workers having little to no control over their schedules and experiencing wild fluctuations in their weekly hours.¹² One study found that the work hours of low-wage service workers varied by an average of 32% from week to week.⁴⁰
• Involuntary Part-Time Work: A significant portion of Medicaid beneficiaries who work part-time do so not by choice, but because of “slack work/business conditions” or an inability to find full-time employment.¹¹ Their hours are capped by their employer.
• Job Churn: The low-wage market is characterized by high rates of job churning, as workers move between short-term jobs or experience periods of episodic employment.⁴²
• Lack of Benefits: These are the very jobs that are least likely to offer affordable, employer-sponsored health insurance, making Medicaid an essential lifeline that allows these individuals to remain in the workforce.¹¹

This reality is completely incompatible with a rigid monthly reporting requirement.

A retail worker could average 90 hours a month over the course of a year, but if their hours are cut to 70 during a slow month in January, they would fail the requirement and be at risk of losing their health coverage for the entire year.²⁴

The policy does not punish a lack of work ethic; it punishes workers for the systemic precarity of the modern economy, a factor entirely outside their control.

It takes the inherent instability of the low-wage labor market and recasts it as a personal failing worthy of the punishment of losing health care.

7.3 The Burden on States: Administrative Costs, Staffing Shortages, and IT Failures

The administrative complexity of work requirements does not only burden beneficiaries; it places an immense and costly strain on state governments.

To comply with the federal mandate, every state will have to design, build, and maintain an entirely new and complex administrative system to track the work hours, exemptions, and compliance status of millions of people every month.¹⁹

The experience of Georgia provides a cautionary tale of the fiscal inefficiency involved.

The state has spent tens of millions of dollars on outside consultants to build a system that has failed to perform its basic functions.⁶

These are taxpayer funds that are diverted from providing actual health care services to funding a bureaucratic apparatus of surveillance and reporting.

This administrative burden also falls on already understaffed and overwhelmed state agencies.

In Georgia, the DFCS was tasked with handling the complex verifications for the Pathways program while already facing high staff turnover and a massive backlog of food stamp and traditional Medicaid applications, predictably leading to errors and delays.⁶

This demonstrates that the time, effort, and stress required for compliance constitute a significant, unquantified “shadow tax” levied on both beneficiaries and the state itself.

For the working poor, time is a critical and finite resource; hours spent on hold with a state agency are hours of lost wages or lost caregiving.

The cumulative burden of this administrative friction is a core, unmeasured cost of the policy.

Section 8: Systemic Consequences and Policy Pathways Forward

The implementation of a national Medicaid work requirement will trigger a cascade of negative consequences that extend far beyond the individuals who lose their coverage.

The policy represents a self-inflicted economic wound for states, threatening to depress local economies, eliminate jobs, and destabilize fragile rural health systems.

This punitive and demonstrably ineffective model stands in stark contrast to evidence-based, supportive programs that have proven successful in helping people find and maintain employment without jeopardizing their health.

The path forward for policymakers requires a clear-eyed assessment of this evidence and a pivot away from punitive mandates toward investments in what actually works.

8.1 Macroeconomic Ripples: State-Level Job Losses and Threats to Rural Hospitals

The federal funds that flow into states through the Medicaid program are a powerful economic engine.

They support jobs not only in hospitals and clinics but also in related sectors, and they generate significant state and local tax revenue.

The OBBB Act’s work requirement, by design, cuts this flow of federal funding.

This reduction in federal spending acts as a negative economic stimulus, with predictable and damaging macroeconomic consequences for states.

According to a detailed economic analysis by the Commonwealth Fund and George Washington University, the imposition of a national work requirement could:

• Reduce Economic Activity: States could see a reduction in their overall economic activity of between $43 billion and $59 billion in the first year alone.²¹
• Trigger Significant Job Losses: The loss of federal health care dollars would lead to the elimination of an estimated 322,000 to 449,000 jobs across the country, primarily in the health care sector.²¹
• Lower Tax Revenues: State and local governments would face a reduction in tax revenues of between $3.2 billion and $4.4 billion, straining their ability to fund other essential services.²¹

The threat is particularly acute for rural hospitals.

As previously noted, these institutions are highly dependent on Medicaid revenue and many are already financially vulnerable.⁹

The loss of revenue resulting from work requirements will push many of them over the brink and into closure.

The closure of a rural hospital devastates the local economy and creates a “health care desert,” harming the entire community’s access to care.⁹

By implementing this policy, states are actively choosing to weaken their own economies and destabilize their health care infrastructure.

8.2 The Inefficiency of Punitive Models vs. the Efficacy of Supportive Programs

The consistent failure of punitive work requirements stands in sharp contrast to the documented success of voluntary employment support programs.

The key difference is one of philosophy and design: punitive models threaten to take away a critical support (health care) as a punishment for not working, while supportive models provide the tools needed to overcome the actual barriers to employment.

• The Punitive Failure: The experiences in Arkansas and Georgia, along with decades of research on TANF, show that simply mandating work without addressing underlying barriers does not lead to sustainable employment gains.¹⁷ It is an expensive and inefficient approach that primarily generates administrative costs and coverage losses.
• The Supportive Success: The state of Montana provides a compelling alternative model. Its “Gateway to Work” program was voluntary and focused on providing personalized support. Staff contacted beneficiaries by phone, conducted individualized assessments, and connected them with services like job search assistance, on-the-job training, and tuition support.⁴³ The program was highly successful: of those who completed training, 91 percent found work.⁴³ This demonstrates that when states invest in addressing the real reasons people aren’t working—lack of skills, training, or support—they can achieve positive results without threatening anyone’s health coverage.

The contrast between these models reveals a fundamental choice for policymakers.

If the genuine goal is to increase employment, the evidence clearly favors voluntary, supportive programs.

The continued pursuit of punitive work requirements, in the face of overwhelming evidence of their failure to promote work, suggests that the policy’s unstated, primary goal may be something else entirely—namely, reducing the number of people on Medicaid rolls through administrative means, regardless of the consequences.

8.3 Recommendations for Federal and State Policymakers

Based on the comprehensive analysis presented in this report, the following policy pathways are recommended to mitigate harm and pursue more effective, evidence-based solutions.

For Federal Policymakers:

1. Repeal the Mandate: The most direct and effective course of action is for Congress to repeal the national work requirement provisions within the OBBB Act. The policy is demonstrably harmful, costly, and ineffective at achieving its stated goals.
2. Maximize Flexibility in Implementation: If repeal is not politically feasible, the Department of Health and Human Services (HHS) must use its regulatory authority to design an implementation rule that minimizes harm. This should include:

• Mandating that states use robust, real-time data matching to automatically verify compliance and exemptions, placing the burden on the state, not the beneficiary.
• Providing significant federal funding and technical assistance to states to build the necessary administrative capacity and IT infrastructure.
• Defining “good cause” exemptions as broadly as possible to protect individuals facing temporary hardships.
• Prohibiting states from requiring monthly reporting, instead allowing for longer and more flexible compliance periods that align with the reality of volatile work.

For State Policymakers:

1. Delay and Design for Minimum Harm: States should use all available flexibility to delay implementation until the last possible moment (December 31, 2028) to allow more time to build less burdensome systems. When designing these systems, states should:

• Eliminate monthly reporting in favor of annual or semi-annual verification.
• Invest heavily in multi-channel outreach and one-on-one assistance to help beneficiaries navigate the process.
• Aggressively use data matching to exempt individuals automatically whenever possible.

2. Refuse to Implement Harmful Policies: Ultimately, states should recognize that implementing this policy is an act against their own economic self-interest and the health of their citizens. They should advocate forcefully at the federal level for repeal or for maximum flexibility to protect their populations.

Alternative Policy Focus:

The most constructive path forward is to abandon the punitive framework of work requirements entirely and shift the policy focus and public investment toward proven, voluntary employment support programs.

Instead of spending billions on a bureaucratic apparatus of surveillance, those funds should be invested in programs that address the actual barriers to work: affordable and accessible childcare, reliable transportation, targeted job training for in-demand fields, and, most critically, the stable foundation of health coverage that Medicaid provides.

This approach aligns with the evidence, promotes genuine economic opportunity, and upholds the foundational purpose of Medicaid as a pillar of health and stability for millions of Americans.

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