Millions of people applying for Medicaid in the coming years will have to prove they work, go to school or volunteer for at least a month before they can get or keep health insurance through the government program.
But Republican lawmakers in some states believe the new rules — part of the GOP’s One Big Beautiful Bill Act, signed last July by President Donald Trump — don’t go far enough.
Indiana is leading the charge, with a new law requiring applicants to prove they have been working or engaged in similar activity for three consecutive months to receive benefits.
Meanwhile, residents in many other states will have to show they’ve worked just one month, the least cumbersome option under Trump’s signature Tax and Domestic Spending Act. It leaves it up to states to decide whether to require one, two or three months of work history.
As in Indiana, Idaho’s Republican lawmakers also approved a three-month requirement, and the state’s governor signed the bill on April 10.
The efforts, along with similar moves in Arizona, Missouri and Kentucky, aim to limit flexibility to implement the federal law at the state level.
“Normally, you wouldn’t see state lawmakers weigh in on these decisions,” said Lucy Dagneau, a senior official at the American Cancer Society’s advocacy arm.
The nonpartisan Congressional Budget Office estimates that 18.5 million adults would be subject to the new rules, which would apply in 42 states and the District of Columbia. In Indiana, the work rules will target about 33% of the state’s Medicaid population. The rules will generally not apply to children, people aged 65 and over or people with disabilities or serious health problems.
Typically, state administrators — not lawmakers — detail how they plan to comply with new federal standards and often seek guidance from federal regulators. But officials at the Centers for Medicare & Medicaid Services have yet to tell states how to comply with many aspects of the sweeping budget law, leaving it up to state lawmakers to step in.
Gov. Mike Braun, a Republican, signed the Indiana bill into law on March 4, making his state the first to set the Medicaid work requirement at three months — the longest period allowed under federal law.
Republican state Sen. Chris Garten introduced a bill in January, saying it was necessary to “bring the state law into line” with new federal Medicaid rules. He also pitched the bill as a way to crack down on “waste, fraud and abuse” in public programs.
When people who don’t qualify sign up, it robs “the really vulnerable Hoosier who really needs the help,” Garten said during a committee hearing in January.
Democratic state Sen. Fady Qaddoura expressed skepticism during the hearing and questioned the necessity of the legislation. Qaddoura asked Indiana Department of Family and Human Services Secretary Mitch Roob to provide an estimate of the number of ineligible people enrolled in Medicaid in the state.
“Very few, I think,” replied Rube. “He will never be any.”
After hearing Roob’s response, Qaddoura said there is no evidence of a widespread problem in Indiana. He accused Republicans of using waste, fraud and abuse as an excuse to deny health benefits and food aid to vulnerable Hoosiers.
Garten later called Qaddoura’s accusation a “fundamental mischaracterization” of the bill.
Republicans have said imposing those limits protects the longevity of the Medicaid program.
“We believe in a safety net for our most vulnerable, not a hammock for able-bodied adults who choose not to work,” Garten said. “By tightening these screws, we ensure that our safety net remains viable.”
Indiana Medicaid enrollment is expected to drop because of Garten’s legislation, according to an analysis by the nonpartisan Indiana Legislative Services Agency.
Medicaid helps people stay healthy so they can continue to work, said Adam Mueller, executive director of the Indiana Justice Project, a nonpartisan legal advocacy organization that focuses on health, housing and food insecurity.
Mueller worries that people will have a harder time proving their work history, especially those in non-traditional jobs.
“If the point is to get people engaged, one month would do it,” Mueller said.
Ultimately, he fears the law will hurt Hoosiers most in need of help. “They will be tripped up by bureaucratic hurdles.”
An analysis by the Center on Budget and Policy Priorities predicted that the work rules will impose new barriers to coverage and that how states choose to implement the rules will “significantly affect the number of people who lose coverage.” State policy decisions will determine exactly “how severe the burden is,” the left-leaning think tank found, and choosing a shorter lookback period “will allow more people to sign up.”
Legislators in several states considered limits. And the same right-wing lobby group, the Foundation for Government Accountability, testified in favor of those measures in Arizona, Indiana and Missouri.
In Missouri, FGA lobbyist James Harris said the measure is intended to “move people out of dependency and give them back that dignity and pride in their work.”
Missouri State Representative Darrin Chappell proposed requiring a three-month review period like the Indiana measure. But the latest version of the bill he sponsored would have required applicants to show they worked for only one month before registering.
Chappell, a Republican, said his initiative would encourage a “working class mentality.”
Anna Meyer, owner of a small bakery in Columbia, Missouri, said the bottom line is that she and others on Medicaid are lazy. “I’ve been working since I was 15,” he said. “I’m 43 now.”
Meyer, who voiced her opposition, said she has had problems in the past submitting information to the state Medicaid agency. She fears the new reporting requirements will put her and others at risk of losing coverage, even if they meet the work rule.
She has fibromyalgia, a chronic condition that increases overall sensitivity to pain. He also has food allergies. Medicaid helps pay for medications and doctor visits that keep her healthy and allow her to continue working.
“I work really hard,” Meyer said.
In St. Louis, Jessica Norton, OB-GYN, treats many Medicaid patients at an Affinia Healthcare clinic. She said they struggle to stay insured even though Missouri extends a full year of Medicaid coverage to eligible women after giving birth. Some of her patients have unexplained initiation of this coverage at the time of their tests six weeks after birth. He fears the red tape from the new work requirements will make it harder to get insurance, even though pregnant women and new mothers are supposed to be exempt.
Norton criticized lawmakers for the message the policy sends to vulnerable patients. They say, ‘Oh, actually, health care is a privilege and you have to earn it,'” she said.
Nearly two-thirds of adults ages 19 to 64 on Medicaid are already working, according to KFF. The reason many of the remaining adults on Medicaid are not working is because they are retired, serving as caregivers or very sick, KFF found.
Some states not only set the most stringent requirements, but also exclude the discretionary leniency built into the federal rules.
For example, states may adopt additional exceptions to work rules, such as allowing people to claim a “short-term hardship,” designed to provide continued Medicaid coverage to people with medical conditions that prevent them from working.
Missouri lawmakers are seeking a constitutional amendment to bar their state from offering such optional exemptions. But patient advocates warn that these limits will hurt the state’s vulnerable residents when they need coverage the most, particularly cancer patients in rural Missouri.
Often, rural Missouri patients must travel to Kansas City or St. Louis for treatment, disrupting their ability to work, Emily Kalmer, an advocacy lobbyist for the American Cancer Society, testified at the January hearing. Recognizing this, federal law provides some exceptions for these types of scenarios.
But that short-term hardship exemption would be off the table in Missouri.
Time is “very important in the life of a cancer patient or cancer survivor,” Kalmer said.
