Millions of people applying for Medicaid in the coming years will need to prove they have worked, attended school or volunteered for at least a month to obtain or maintain health insurance through the government program.
But Republican lawmakers in some states don’t think the new rules, part of the GOP’s One Big Beautiful Bill Act, signed by President Donald Trump last July, go far enough.
Indiana is at the forefront of this movement, enacting a new law that requires applicants to prove they have worked or participated in similar activities for three consecutive months in order to receive benefits.
Meanwhile, residents in many other states must prove they’ve worked just one month, the most onerous option under President Trump’s signature Tax and Appropriations Act. The bill directs each state to decide whether to require one, two, or three months of work experience.
Like Indiana, Idaho Republican lawmakers approved a three-month period, and the state’s governor signed the bill on April 10.
The effort, similar to similar moves in Arizona, Missouri and Kentucky, aims to limit the state’s flexibility to enforce federal law.
“Typically, state legislatures don’t have a hand in these decisions,” said Lucy Daugneau, a senior advocate in the American Cancer Society’s advocacy division.
The nonpartisan Congressional Budget Office estimates that 18.5 million adults will be subject to the new rules, which will be implemented in 42 states and the District of Columbia. In Indiana, work rules cover about 33% of the state’s Medicaid population. This rule generally does not apply to children, people over 65, people with disabilities, or people with serious health problems.
State administrators, rather than lawmakers, typically spell out how they plan to comply with new federal standards, often seeking guidance from federal regulators. But Centers for Medicare and Medicaid Services officials have not yet told states how to comply with many aspects of the sweeping budget law, leaving it up to state legislatures to intervene.
Republican Gov. Mike Brown signed the Indiana bill on March 4, making the state the first to set Medicaid work requirements at three months, the maximum period allowed by federal law.
Republican state Sen. Chris Garten introduced the bill in January, saying it would be necessary to “align” state law with new federal Medicaid rules. He also proposed the bill as a way to crack down on “waste, fraud and abuse” in public works projects.
Garten said at a committee hearing in January that registering ineligible people would deprive “genuinely vulnerable Hoosiers who actually need help.”
Democratic state Sen. Fadi Kadoura expressed skepticism during the hearing, questioning the bill’s necessity. Kadura asked Indiana Department of Family and Human Services Secretary Mitch Lube to provide an estimate of the number of ineligible people enrolled in Medicaid in the state.
“I don’t think there are many,” Rube replied. “That doesn’t mean it doesn’t exist.”
After hearing Lube’s answer, Kadura said there was no evidence the problem was widespread in Indiana. He accused Republicans of justifying waste, fraud and abuse to deny health benefits and food assistance to vulnerable Hoosiers.
Garten later said Kadura’s accusations were a “fundamental error” in the bill.
Republicans argue that imposing such restrictions will protect the viability of the Medicaid system.
“We believe in a safety net for the most vulnerable, not a hammock for able-bodied adults who choose not to work,” Garten said. “Tightening these screws will ensure that our safety net remains sustainable.”
Indiana’s Medicaid enrollment is expected to decline because of Garten’s bill, according to an analysis by the Indiana Bipartisan Legislative Office.
Medicaid helps people stay healthy and keep working, said Adam Muller, executive director of the Indiana Justice Project, a nonpartisan legal advocacy group focused on health, housing and food insecurity.
Mueller worries that people, especially those in non-traditional jobs, will have a hard time proving their work history.
“If your goal is to get people interested, a month might be enough,” Mueller said.
Ultimately, he worries this legislation will hurt Hoosiers who need help the most. “They’re going to run into bureaucratic hurdles.”
The Center on Budget and Policy Priorities’ analysis predicted that the work rule would impose new barriers to coverage and that how states choose to implement the rule would “have a significant impact on the number of people who lose insurance.” The left-wing think tank says national policy decisions will determine “how severe the burden will be,” and that choosing a shorter look-back period would “enable more people to enroll.”
Lawmakers in several states have considered the limits. And the same right-wing lobbying group, the Government Accountability Foundation, testified in support of these measures in Arizona, Indiana, and Missouri.
In Missouri, FGA lobbyist James Harris said the measure aims to “free people from addiction and restore dignity and pride in their work.”
Representative Darin Chappell of Missouri proposed requiring a three-month lookback period similar to Indiana’s measure. But the latest version of his proposed bill would require applicants to prove they have only worked for one month before enrolling.
Chappell, a Republican, said his initiative promotes a “work mindset.”
Anna Meyer, a small bakery owner in Columbia, Missouri, said this suggests she and other Medicaid recipients are lazy. “I’ve been working since I was 15,” she said. “I’m 43 years old now.”
Meyer, who voiced her opposition, said she previously had problems submitting information to the state Medicaid agency. She worries the new reporting requirements could put her and others at risk of losing coverage, even if they meet work regulations.
She has fibromyalgia. This is a chronic disease that increases the overall sensitivity to pain. She also has food allergies. Medicaid helps pay for medications and doctor’s visits to keep her healthy and able to continue working.
“I work very hard,” Meyer said.
Jessica Norton, a St. Louis obstetrician-gynecologist, treats many Medicaid patients at Affinia Healthcare Clinic. Even though Missouri extends Medicaid coverage for a full year for eligible women after giving birth, she said, they struggle to maintain coverage. Some of her patients mysteriously lose insurance coverage by the time of their six-week checkup. Pregnant women and new mothers should be exempt, but she worries the red tape of the new work requirements will make it harder to stay covered.
Norton criticized lawmakers for saying the policy sends a message to vulnerable patients. They said, “Oh, actually, health care is a privilege and you have to earn it,” she said.
According to KFF, nearly two-thirds of adults between the ages of 19 and 64 who receive Medicaid are already working. The KFF study found that many of the remaining adults receiving Medicaid are not working because they are retired, working as caregivers, or are sick.
Some states not only set the most stringent requirements, but also block the optional leniency built into federal regulations.
For example, states may adopt additional exemptions from work rules, such as allowing people to claim “short-term hardship,” in an effort to continue Medicaid coverage for people with medical conditions that prevent them from working.
Missouri lawmakers are seeking a constitutional amendment that would prohibit the state from offering such discretionary exemptions. But patient advocates warn that these restrictions will harm the state’s vulnerable populations who need coverage the most, especially cancer patients in rural Missouri.
In many cases, patients in rural Missouri have to travel to Kansas City or St. Louis for treatment, disrupting their ability to work, Emily Kalmer, a lobbyist with the American Cancer Society’s advocacy division, testified at a hearing in January. Recognizing this, federal law provides certain exceptions for this type of scenario.
However, this short-term hardship exemption would not be applicable in Missouri.
Time is “very important in the lives of cancer patients and cancer survivors,” Kalmar said.
