As work requirements kick in for Medicaid, some states are taking a
tougher stance
[September 26, 2026]
By GEOFF MULVIHILL
Work requirements for some Medicaid beneficiaries begin across the U.S.
in January, the result of President Donald Trump's big 2025 tax cut and
policy law, and a handful of Republican-led states are imposing tougher
rules than the law requires.
At issue is how someone can prove they are too medically frail to work.
While federal regulations say the state can take the recipient's word
for it for the first year, at least six states are requiring
documentation immediately. There is a continuing push in other states to
follow suit eventually.
Advocates say that could create problems, especially for new applicants
to the joint state-federal health insurance program for lower-income
people.
“Someone may not be able to work, but they can’t see a doctor because
they can’t afford it. So they’re now applying for Medicaid,” said
Jennifer Tolbert, director of state health policy and data at the
research organization KFF. “But Medicaid is saying you need
documentation from a provider.”
As some Republican-led states take a tougher-than-required approach to
implementing the federally mandated changes, Democrats in 25 states are
suing and asserting that the rules are too harsh.
Some say documentary evidence is necessary to avoid fraud
The Medicaid changes are projected to save the federal government $887
billion over the next decade and result in 7.5 million fewer people with
health insurance, according to the Congressional Budget Office’s 2025
estimate.
The conservative Foundation for Government Accountability has been
pushing states not to make it too easy for people to avoid work
requirements, saying able-bodied adults are pushing enrollment and costs
higher.
Jonathan Ingram, vice president of research and policy at the group, has
been encouraging states not to take a beneficiary’s word for it, a
process known as self-attestation.
“Self-attestation is fraud-by-design,” he said via email. “It is a
policy developed by bureaucrats to maximize enrollment at the expense of
program integrity.”
Self-attestation comes under penalty of perjury, so people who lie can
be subject to criminal charges — though such charges are rare.
Arkansas, Idaho, Indiana, New Hampshire, North Carolina and Ohio all
have laws or policies that bar self-attestation to qualify for the work
requirement exception starting next year.
Republican Missouri state Rep. Darin Chappell said he worked with the
Foundation for Government Accountability to craft a proposed amendment
that would have enshrined Medicaid work requirements in the state
constitution. It would have required “documentary evidence” of work or
reasons for exemptions, specifically prohibiting self-attestation.
The amendment passed the Missouri House but died without a vote in the
Senate. Chappell plans to try again next year.
“If someone has a debilitating physical ailment — or mental ailment for
that matter — something that prohibits them from working, that’s totally
legitimate,” he said. “But we’re not taking anybody’s word for it. I
don’t mean to shock you none, but people do tend to lie about such
things.”
Most nondisabled beneficiaries under 65 already work
The new mandate applies to up to 20 million lower-income adults without
children at home who are enrolled in Medicaid through an optional
expansion in 40 states and the District of Columbia. The requirement
does not apply in the 10 states, mostly in the South, that did not
expand Medicaid.
Beneficiaries will have to work or volunteer at least 80 hours each
month or be in school at least half-time to qualify, with exceptions for
situations including medical frailty.
The law had said medically frail people include those who have substance
use disorders, disabilities or serious medical conditions. But the
Centers for Medicare and Medicaid Services published a rule in June that
went further and was stricter than states and providers expected, saying
someone’s condition must “significantly impair” their ability to work,
volunteer or attend school as required for an exemption.
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Workers at a Medicaid call center in Jefferson City, Mo.,
field questions and review information regarding eligibility
determinations on Wednesday, Aug. 16, 2023. (AP Photo/David A. Lieb,
FIle)
 Currently states generally decide
once a year whether Medicaid recipients still qualify for benefits.
The new law will require it to happen twice for most enrollees.
States will be allowed to accept self-attestation just once each
time a person enrolls starting in 2028. After that, documentation
would be required at least every 12 months to verify that they still
have the condition and that it still prevents them from being able
to work.
The government expects states to rely increasingly on third-party
data — on things such as workers’ compensation claims or
prescription information — to help make determinations. For
conditions that do not show up in the databases, states can require
a doctor's certification, a disability award letter or other proof.
While states have been ramping up the use of this information, the
work requirements are still a big change, and many will first have
to spend millions of dollars improving their computer systems.
States are already struggling in some cases to make changes to the
Supplemental Nutrition Assistance food program, or SNAP, that are
required under Trump's law, including an expanded work requirement.
In Arizona, for example, enrollment plummeted by 55% from April 2025
to April 2026 — the biggest drop in the country — with more than
400,000 fewer people getting benefits now. Last month, the state
said that was largely due to difficulties in putting in place new
federal requirements that resulted in higher call volumes and
additional verification.
Patient advocates worry aid will be denied to qualified people
Ingram said some of the concerns about ending self-attestation are
overblown and people can get diagnoses to support their inability to
work at many places, including charitable clinics and federally
qualified health centers. He also noted that Medicaid allows
retroactive coverage for doctor visits that happen before
enrollment.
Patient advocates say it's not that simple.
“The added paperwork, the hoops you have to jump through lead to
coverage loss,” said Nate Crippes, a lawyer at the Disability Law
Center in Utah, where a law allows self-attestation to qualify for
the work requirement exception on a provisional basis.
An added challenge is that most people in the Medicaid expansion
group in his state have a mental health or substance use disorder
diagnosis — or both.
“We’re choosing to make people with health conditions jump through a
bunch of hurdles,” said Camille Richoux, health policy director at
Arkansas Advocates for Children and Families.
It can be tricky if states decide to rely partly on patient
diagnosis codes to determine whether recipients are able to work.
Lucy Dagneau, senior director of the state and local campaigns team
at the American Cancer Society Cancer Action Network, said the codes
do not indicate the severity of a condition. For example, some
patients with a specific cancer can continue working, she said, but
others who are in more advanced stages cannot.
“Our fear is by that banning self-attestation, unfortunately, the
state lawmakers who pass those laws are going to have a hand in more
people losing coverage in their state than would have,” she said.
____
Associated Press writers David A. Lieb in Jefferson City, Missouri,
and Laura Turbay in Little Rock, Arkansas, contributed.
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