Several conservative states will require proof from people who say they're too sick to work.
Democrats say the Trump administration’s new Medicaid work requirements — especially the narrow definition of who can get an exemption for medical reasons — are way too harsh.
Conservatives contend they’re not tough enough, and have convinced some Republican-led states to be even stricter.
Democrats say the Trump administration’s new Medicaid work requirements — especially the narrow definition of who can get an exemption for medical reasons — are way too harsh.
Conservatives contend they’re not tough enough, and have convinced some Republican-led states to be even stricter.
The federal government gave states the option of allowing people to stay on Medicaid through 2027 if they declare themselves too sick to work, with verification starting in 2028. But at least eight states are rejecting that grace period and demanding proof earlier. Starting in January, Arkansas, Idaho, Indiana, Iowa, North Carolina, North Dakota, Ohio, and Utah will impose work rules stricter than those the administration is requiring.
Their decision underscores many conservatives’ belief that the expansion of Medicaid under Obamacare covered too many people that they consider unworthy of support, such as non-disabled, working-age adults without children. Democrats and advocates for low-income people say the harsher enforcement will cause many more sick people to join the ranks of the uninsured faster, putting the burden of caring for them on already-strained emergency rooms and public health clinics.
The policies adopted by the eight GOP-leaning states are the culmination of a massive lobbying campaign by conservative organizations who view the administration’s decision to forgo verification of medical frailty next year as a “loophole” that people will exploit to get out of working.
Jonathan Ingram, the vice president of policy and research at the Foundation for Government Accountability, a conservative think tank and advocacy group, said in an interview that his organization spent the last year deploying lobbyists and “encouraging lawmakers across the country” to pass bills requiring Medicaid recipients to prove they’re too sick to work starting next year, and imposing other “strong guardrails…. so agency bureaucrats can’t come in and undermine the work that Congress did.”
Several states did adopt such legislation — over the objections of Democratic lawmakers. In others, the move towards tougher enforcement came from the health department.
“They sprung into action to put in as many impediments as possible to people remaining on Medicaid,” said Idaho Democratic Rep. Ilana Rubel, the minority leader in the statehouse who argued against the bill requiring strict enforcement of the work requirement, which the governor signed into law earlier this year. “We’re already lowest in the nation per capita for health care providers, and I think it will get substantially worse when they finally attain their dream of kicking tens of thousands more people off of their health insurance.”
The new work rules stem from the One Big Beautiful Bill Act that Republicans in Congress passed last year requiring Medicaid enrollees to work, volunteer or study at least 80 hours per month. The policy applies to the 21 million or so people who gained eligibility for Medicaid through Obamacare, and nonpartisan analysts expected it to drive up the number of people who lose Medicaid by at least 5 million over a decade.
An analysis by the health consulting firm Manatt of states that previously enacted their own Medicaid work rules found that states that allowed patients to retain coverage if they claimed to have a serious medical condition — a practice called “self-attestation” — saw far fewer people lose their coverage.
Arkansas granted exemptions to its state work requirement when patients said they were too sick to work, and saw around 29 percent of its Medicaid patients lose coverage. Yet in New Hampshire, which only allowed parents of young children and other narrow categories to claim such an exemption without state verification, more than 40 percent were projected to lose coverage before a court ruling blocked the policy from taking effect.
Health policy experts stress that eligible people are still likely to lose coverage in the majority of states that are planning to allow patients to cite an illness to get an exemption from the work requirement — either because they are unaware of the option or unable to navigate the bureaucracy.
“Requiring individuals to go get documentation from their provider to demonstrate their medical frailty is going to place such a significant burden on people to make the appointment, to obtain the documentation, to put the stress on the provider, to make that assessment,” said Kinda Serafi, a partner at Manatt Health. “People who live in rural areas, people who live in states that have provider shortages, or there’s a lack of transportation, are going to really struggle to document medical frailty, even if they clearly qualify.”
The Foundation for Government Accountability, whose work has been funded by the Koch family and other GOP megadonors, has spent more than a decade pushing states to restrict access to the social safety net. In the last few years, its lobbyists worked to convince legislatures to make it harder for people to access SNAP, Medicaid and other public benefit programs.
Over the last year, the group contracted with lobbyists in Idaho, Indiana, Missouri, Montana, Nebraska, North Carolina, and Utah to push lawmakers to enact legislation to implement strict Medicaid work requirements — with provisions that go beyond the parameters set by the Trump administration.
In particular, the group urged state lawmakers to turn down the federal government’s offer of a one-year grace period that allows patients to sign a sworn statement under penalty of perjury that they are medically frail without having to provide a doctor’s note or other evidence.
“We’ve recommended it to any state that will listen to us,” said Ingram. “We are trying to preach the gospel of work and the value of work.”
Ingram pointed to the implementation of work requirements for the SNAP food program in 1996 as a cautionary tale, lamenting that blue states “went after as many exemptions and waivers as possible.”
Watch: The Conversation
Dasha Burns presses Mike Johnson on the economy, Iran and Trump's agenda
37:20
Dasha Burns presses Mike Johnson on the economy, Iran and Trump's agenda
Now the group is eyeing Medicaid.
“We’ve seen audit after audit that shows if you are not verifying what people tell you then you are getting a lot of people who are ineligible,” he said. “We view that as essentially fraud by design. These are policies designed by bureaucrats to allow essentially legalized fraud.”
In many places, the group’s call for tougher enforcement met a receptive audience. Many state and federal Republicans argue that strict work requirements are needed because Medicaid spending growth in recent years — more than double the rate of inflation — has put the program on unstable footing.
The federal government pays the bulk of Medicaid expansion costs, but states manage the programs individually. Removing people who can’t prove they are either working or sick, conservatives contend, will help ensure coverage for the single parents and disabled people the program served before Obamacare.
North Carolina’s Republican-controlled legislature passed a bill earlier this year that prohibits state and county officials “from accepting self-attestation as the only evidence in verification of Medicaid eligibility requirements, including new Medicaid work requirements,” the state’s health department confirmed in a statement to POLITICO.
“North Carolina has done what is necessary to comply with federal laws while focusing anew on wasteful spending, fraud and abuse in health care,” said Republican Rep. Donny Lambeth, who voted in favor of expanding Medicaid in 2023. “We are just complying with federal laws while working with the counties to help them lower their eligibility error rates.”
While several states claimed an ideological or fiscal motivation for demanding proof of illness earlier than the Trump administration mandated, others said they were doing so to avoid confusion that may result from having one policy in 2027 and another in 2028.
“A consistent verification process also ensures a tracking record for future reviews,” North Dakota’s Medicaid agency said in a statement.
Iowa’s health department echoed that rationale, telling POLITICO it will use “a single, standardized process to provide clarity for both members and eligibility workers.”
In Idaho, under a law the legislature passed overwhelmingly this spring, new Medicaid patients can claim an exemption for medical frailty for the first six months of the work rules, but will have to show proof when their coverage is renewed and when the state conducts eligibility checks every six months after that.
Rubel, the Idaho Democrat, is worried that proof of illness will be hard to come by for her Boise constituents due to doctor shortages in the area.
“I have private health insurance, and I’m regularly told it’s a six-to-eight month waiting list,” she said.
Ohio’s Medicaid agency is confronting similar challenges as it joins the cadre of states rejecting the Trump administration’s one-year grace period. Its Medicaid agency told POLITICO it is working with federal health officials to come up with a solution for medically frail people newly enrolling in Medicaid who do not have access to a doctor and aren’t able to obtain an examination and diagnosis.
“We’re falling into the idea that health care is a privilege. It’s just horrible,” said Anita Somani, a Democrat and OB/GYN who represents the Columbus area in the Ohio legislature. “And we’re already seeing the real world consequences in our medical practices. People are canceling surgeries. They’re rationing their meds because they can’t fill the prescription until their next paycheck.”
What kind of documentation to require of sick patients on Medicaid is a conundrum facing many states as the 2027 implementation deadline draws near.
Hilarie Matlock, the policy director for the advocacy group Idaho Voices for Children, said uninsured sick people will face a Catch-22: they can’t get Medicaid without first seeing a doctor to get proof of their condition, but they can’t afford to see a doctor without insurance.
Self-attestation, she noted, has long been accepted in Medicaid for things such as income, and she disagrees with conservative advocates who view it as a loophole.
“It is not simply taking a person’s word for it,” said Matlock. “It is a sworn statement made under penalty of perjury.”
Conservatives contend they’re not tough enough, and have convinced some Republican-led states to be even stricter.
The federal government gave states the option of allowing people to stay on Medicaid through 2027 if they declare themselves too sick to work, with verification starting in 2028. But at least eight states are rejecting that grace period and demanding proof earlier. Starting in January, Arkansas, Idaho, Indiana, Iowa, North Carolina, North Dakota, Ohio, and Utah will impose work rules stricter than those the administration is requiring.
Their decision underscores many conservatives’ belief that the expansion of Medicaid under Obamacare covered too many people that they consider unworthy of support, such as non-disabled, working-age adults without children. Democrats and advocates for low-income people say the harsher enforcement will cause many more sick people to join the ranks of the uninsured faster, putting the burden of caring for them on already-strained emergency rooms and public health clinics.
The policies adopted by the eight GOP-leaning states are the culmination of a massive lobbying campaign by conservative organizations who view the administration’s decision to forgo verification of medical frailty next year as a “loophole” that people will exploit to get out of working.
Jonathan Ingram, the vice president of policy and research at the Foundation for Government Accountability, a conservative think tank and advocacy group, said in an interview that his organization spent the last year deploying lobbyists and “encouraging lawmakers across the country” to pass bills requiring Medicaid recipients to prove they’re too sick to work starting next year, and imposing other “strong guardrails…. so agency bureaucrats can’t come in and undermine the work that Congress did.”
Several states did adopt such legislation — over the objections of Democratic lawmakers. In others, the move towards tougher enforcement came from the health department.
“They sprung into action to put in as many impediments as possible to people remaining on Medicaid,” said Idaho Democratic Rep. Ilana Rubel, the minority leader in the statehouse who argued against the bill requiring strict enforcement of the work requirement, which the governor signed into law earlier this year. “We’re already lowest in the nation per capita for health care providers, and I think it will get substantially worse when they finally attain their dream of kicking tens of thousands more people off of their health insurance.”
The new work rules stem from the One Big Beautiful Bill Act that Republicans in Congress passed last year requiring Medicaid enrollees to work, volunteer or study at least 80 hours per month. The policy applies to the 21 million or so people who gained eligibility for Medicaid through Obamacare, and nonpartisan analysts expected it to drive up the number of people who lose Medicaid by at least 5 million over a decade.
An analysis by the health consulting firm Manatt of states that previously enacted their own Medicaid work rules found that states that allowed patients to retain coverage if they claimed to have a serious medical condition — a practice called “self-attestation” — saw far fewer people lose their coverage.
Arkansas granted exemptions to its state work requirement when patients said they were too sick to work, and saw around 29 percent of its Medicaid patients lose coverage. Yet in New Hampshire, which only allowed parents of young children and other narrow categories to claim such an exemption without state verification, more than 40 percent were projected to lose coverage before a court ruling blocked the policy from taking effect.
Health policy experts stress that eligible people are still likely to lose coverage in the majority of states that are planning to allow patients to cite an illness to get an exemption from the work requirement — either because they are unaware of the option or unable to navigate the bureaucracy.
“Requiring individuals to go get documentation from their provider to demonstrate their medical frailty is going to place such a significant burden on people to make the appointment, to obtain the documentation, to put the stress on the provider, to make that assessment,” said Kinda Serafi, a partner at Manatt Health. “People who live in rural areas, people who live in states that have provider shortages, or there’s a lack of transportation, are going to really struggle to document medical frailty, even if they clearly qualify.”
The Foundation for Government Accountability, whose work has been funded by the Koch family and other GOP megadonors, has spent more than a decade pushing states to restrict access to the social safety net. In the last few years, its lobbyists worked to convince legislatures to make it harder for people to access SNAP, Medicaid and other public benefit programs.
Over the last year, the group contracted with lobbyists in Idaho, Indiana, Missouri, Montana, Nebraska, North Carolina, and Utah to push lawmakers to enact legislation to implement strict Medicaid work requirements — with provisions that go beyond the parameters set by the Trump administration.
In particular, the group urged state lawmakers to turn down the federal government’s offer of a one-year grace period that allows patients to sign a sworn statement under penalty of perjury that they are medically frail without having to provide a doctor’s note or other evidence.
“We’ve recommended it to any state that will listen to us,” said Ingram. “We are trying to preach the gospel of work and the value of work.”
Ingram pointed to the implementation of work requirements for the SNAP food program in 1996 as a cautionary tale, lamenting that blue states “went after as many exemptions and waivers as possible.”
Watch: The Conversation
Dasha Burns presses Mike Johnson on the economy, Iran and Trump's agenda
37:20
Dasha Burns presses Mike Johnson on the economy, Iran and Trump's agenda
Now the group is eyeing Medicaid.
“We’ve seen audit after audit that shows if you are not verifying what people tell you then you are getting a lot of people who are ineligible,” he said. “We view that as essentially fraud by design. These are policies designed by bureaucrats to allow essentially legalized fraud.”
In many places, the group’s call for tougher enforcement met a receptive audience. Many state and federal Republicans argue that strict work requirements are needed because Medicaid spending growth in recent years — more than double the rate of inflation — has put the program on unstable footing.
The federal government pays the bulk of Medicaid expansion costs, but states manage the programs individually. Removing people who can’t prove they are either working or sick, conservatives contend, will help ensure coverage for the single parents and disabled people the program served before Obamacare.
North Carolina’s Republican-controlled legislature passed a bill earlier this year that prohibits state and county officials “from accepting self-attestation as the only evidence in verification of Medicaid eligibility requirements, including new Medicaid work requirements,” the state’s health department confirmed in a statement to POLITICO.
“North Carolina has done what is necessary to comply with federal laws while focusing anew on wasteful spending, fraud and abuse in health care,” said Republican Rep. Donny Lambeth, who voted in favor of expanding Medicaid in 2023. “We are just complying with federal laws while working with the counties to help them lower their eligibility error rates.”
While several states claimed an ideological or fiscal motivation for demanding proof of illness earlier than the Trump administration mandated, others said they were doing so to avoid confusion that may result from having one policy in 2027 and another in 2028.
“A consistent verification process also ensures a tracking record for future reviews,” North Dakota’s Medicaid agency said in a statement.
Iowa’s health department echoed that rationale, telling POLITICO it will use “a single, standardized process to provide clarity for both members and eligibility workers.”
In Idaho, under a law the legislature passed overwhelmingly this spring, new Medicaid patients can claim an exemption for medical frailty for the first six months of the work rules, but will have to show proof when their coverage is renewed and when the state conducts eligibility checks every six months after that.
Rubel, the Idaho Democrat, is worried that proof of illness will be hard to come by for her Boise constituents due to doctor shortages in the area.
“I have private health insurance, and I’m regularly told it’s a six-to-eight month waiting list,” she said.
Ohio’s Medicaid agency is confronting similar challenges as it joins the cadre of states rejecting the Trump administration’s one-year grace period. Its Medicaid agency told POLITICO it is working with federal health officials to come up with a solution for medically frail people newly enrolling in Medicaid who do not have access to a doctor and aren’t able to obtain an examination and diagnosis.
“We’re falling into the idea that health care is a privilege. It’s just horrible,” said Anita Somani, a Democrat and OB/GYN who represents the Columbus area in the Ohio legislature. “And we’re already seeing the real world consequences in our medical practices. People are canceling surgeries. They’re rationing their meds because they can’t fill the prescription until their next paycheck.”
What kind of documentation to require of sick patients on Medicaid is a conundrum facing many states as the 2027 implementation deadline draws near.
Hilarie Matlock, the policy director for the advocacy group Idaho Voices for Children, said uninsured sick people will face a Catch-22: they can’t get Medicaid without first seeing a doctor to get proof of their condition, but they can’t afford to see a doctor without insurance.
Self-attestation, she noted, has long been accepted in Medicaid for things such as income, and she disagrees with conservative advocates who view it as a loophole.
“It is not simply taking a person’s word for it,” said Matlock. “It is a sworn statement made under penalty of perjury.”