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Republicans say that able-bodied adults who don’t work would lose Medicaid coverage under the House tax-cuts-and-spending bill, while Democrats say the legislation would hurt vulnerable groups. The bill’s main target is those able-bodied adults, but other groups would lose coverage due to paperwork burdens and other provisions in the bill, health policy experts say.
The majority of coverage losses under the bill would come from those who became eligible for Medicaid due to an expansion of the program under the Affordable Care Act — those enrollees would face new work requirements unless they were subject to an exemption.
“The challenge here is that these work requirements also become sort of a paperwork requirement,” Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at the health policy research group KFF, told us in an interview. In order to keep their Medicaid coverage, people have to document that they’re working the required number of hours or meet the criteria for an exemption. It’s not yet known what kind of documents will be required, she said, but it’s “quite likely that there will be people … who have reported disabilities, who have other chronic conditions, and … who are caring for children or elderly parents, who may also lose coverage” because they aren’t able to provide the correct documents.
Overall, the nonpartisan Congressional Budget Office estimated that the bill would lead to 10.9 million more people being uninsured in 2034, with 7.8 million of those due to the bill’s Medicaid provisions and the rest due to changes concerning the Affordable Care Act’s insurance marketplaces. The House narrowly passed the bill on May 22, and the Senate is now considering it.
House Speaker Mike Johnson and other Republican lawmakers have said that those losing insurance coverage would be people who shouldn’t have received it in the first place.
“The numbers of Americans who are affected are those that are entwined in our work to eliminate fraud, waste and abuse,” Johnson said on CNN’s “State of the Union” on May 25. He claimed that “pregnant women and young single mothers, the disabled, the elderly … are protected” under the bill.
The House speaker and other Republicans have said the bill, called the One Big Beautiful Bill Act, actually saves the Medicaid program, even though it cuts federal Medicaid spending. In a May 20 statement, Rep. Tom Cole of Oklahoma said the bill “stops the subsidization of competent adults who are just choosing to not work.”
KFF estimated that the bill would reduce federal Medicaid spending by a net $793 billion over 10 years, based on CBO’s analysis. That’s a 12% reduction in federal Medicaid funding. Yet, Johnson has claimed that the spending cuts aren’t cuts at all. “There are no Medicaid cuts in the Big Beautiful Bill. We’re not cutting Medicaid,” he said on NBC’s “Meet the Press” on June 1. “What we’re doing is strengthening the program. We’re reducing fraud, waste and abuse that is rampant in Medicaid to ensure that that program is essential for so many people, ensure that it’s available for the most vulnerable.”
(Johnson has also cited “more than 1.4 million illegal aliens on Medicaid.” We’ve already written about that false claim. The CBO said those individuals would lose coverage from “state-only funded programs,” not from Medicaid. The bill would reduce federal Medicaid funding to states that continue their own health insurance programs for immigrants in the U.S. illegally.)
Democrats, meanwhile, have focused on potential impacts on “vulnerable” groups.
Democratic Sen. Michael Bennet of Colorado said on CNN on May 25 that Johnson’s comments about “able-bodied adults” and “illegal aliens” were “not true.” Bennet said the House bill would drive “a lot” of health care providers “out of business,” and suggested that kids and families in poverty would be affected by the Medicaid provisions.
The bill has financial implications for some providers, such as community health centers and hospitals, but it’s unclear to what extent they would close as a result. Tolbert said “it will be hard to say” if closures are directly related to the bill.
In a May 27 press conference, Sen. Elizabeth Warren said that “every one” of the approximately 2 million people on Massachusetts’ Medicaid program “will be at risk of losing their health coverage” under the Republican bill.
Leonardo Cuello, a research professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families, told us: “Basically every type of Medicaid enrollee could be at risk of coverage loss.”
But, of course, the vast majority of Medicaid enrollees wouldn’t be expected to lose coverage, even if many are “at risk,” as Warren put it. The health insurance program for low-income individuals covers about 83 million people and is jointly funded by the federal government and the states. Coverage losses would vary by state – and there’s uncertainty about how states would react to the bill’s changes. But KFF estimated that Massachusetts’ enrollment would drop by 11% in 2034 under the bill.
Nationwide, Medicaid projected enrollment would decline by 12% in 2034, KFF said.
We’ll go through what the bill would do and how it could affect Medicaid enrollees.
The Bill’s Work Requirements
A large portion of the Medicaid savings in the bill come from new work requirements, or what the legislation calls “community engagement,” for adults who gained coverage under a Medicaid expansion in the Affordable Care Act. This aspect of the bill saves an estimated $344 billion over 10 years.
Forty states plus Washington, D.C., have implemented that Medicaid expansion. It broadened eligibility to adults under age 65 who earn up to 138% of the federal poverty level, and the federal government provides 90% of the funding for that population. The income eligibility threshold before that varied by state.
The expansion population was estimated at 21.3 million people in 2024, according to KFF.
The House bill would require those in the expansion group ages 19 to 64 to work, or participate in community service or job training, for a minimum of 80 hours per month. Attending an educational program at least half-time would also qualify, as would earning income equivalent to 80 hours’ worth of minimum-wage work.
States would be required to exempt certain groups, including pregnant people, parents and caretakers of dependent children and disabled family members, people with substance use disorders and some medical conditions, some people with disabilities, and those who had been in foster care as children, according to a breakdown of the bill by Georgetown University’s Center for Children and Families.
States would need to confirm that requirements were met for at least one month before someone applied for Medicaid or renewed their eligibility, and those renewals must happen at least twice a year. The work requirements would have to be instituted no later than Dec. 31, 2026.
Impact of Work Requirements
The CBO estimated that Medicaid coverage would drop by 5.2 million people in 2034 because of the work requirement provision, with 4.8 million being uninsured. Its June 4 letter on these figures said that 18.5 million would be subject to the requirement, though “some” would be exempt.
It’s unclear how many are “able-bodied” and choosing not to work.
Studies have found a small percentage of Medicaid enrollees would fit that description. In an analysis of 2024 Census Bureau survey data, KFF determined that 8% of Medicaid recipients under age 65 and not also getting Social Security disability benefits weren’t working because they were retired, unable to find work or another reason. The Center on Budget and Policy Priorities found that half of that group was retired.
Nearly two-thirds – 64% – were working full-time or part-time, and the rest weren’t working due to a disability or illness, caregiving responsibilities, or being a student.
Johnson has referred to “about 4.8 million able-bodied workers, young men, for example, who are on Medicaid and not working. They are choosing not to work when they can,” calling this “fraud.” But the 4.8 million figure is the CBO estimate of the number who would become uninsured due to the work requirements. The House Energy and Commerce Committee, in a post on X, said these were all “able bodied adults choosing not to work.”
It’s unknown how many of those individuals fit Johnson’s description. We contacted the House speaker’s office about this figure and his other claims, but we haven’t received a response.
Tolbert told us she didn’t know if a CBO breakdown would be able to provide details of what types of Medicaid enrollees will lose coverage under the work requirements, such as single adults, parents or those with disabilities.
“It is patently false that the impact is only going to be on able-bodied individuals,” Cuello said, adding that many people with disabilities aren’t enrolled with an official disability determination and instead are in the expansion population.
Michael Karpman, a principal research associate in the health policy division at the Urban Institute, told us that if there’s a group of enrollees in the expansion population that should be working but choose not to “it’s small.” The think tank has found that at least 90% of the adults in the expansion population “are working … are in fair or poor health or have a disability, likely have some caregiving responsibilities, or are looking for work. And so most people, the vast majority of people, are participating in the activities prescribed by the policy, or could potentially meet the exemption criteria from the work requirement.”
But “in practice,” he said, “a lot of people who are likely to qualify for an exemption are not going to actually get that exemption” because they’ll have trouble with the reporting requirements. “That’s what we saw in states that previously implemented work requirements. Some people were automatically exempted by the state; most of those who weren’t had difficulty with the reporting bureaucracy in terms of showing that they were exempt or meeting the work requirement.”
Two states have tried such requirements.
In Arkansas, which implemented work requirements for Medicaid in 2018, more than 18,000 adults were disenrolled that year. A federal court ruling stopped the program in 2019, after a group of Medicaid enrollees in the state sued. The case provided anecdotal evidence of the problems people had with the reporting requirements. One man in his 40s, who worked at a poultry business, successfully filed documentation at first but then lost coverage when he was unaware that he needed to keep doing so monthly.
An Urban Institute study found that the work requirement was associated with an increase in the uninsured among the target group for the policy, 30- to 49-year-olds with low incomes. But researchers didn’t find changes in employment.
And in Georgia, which, like the House bill, requires proof of work before enrolling applicants, “very few people who are eligible for the program have been able to enroll,” Karpman said.
As of April 30, the state had enrolled about 7,400 low-income adults since the program launched in July 2023, but the state had expected to enroll 47,000 in the first two years. The Georgia Budget & Policy Institute has said 240,000 people in the state are “potentially eligible.”
Jennifer Haley, also a principal research associate at the Urban Institute, told us that states won’t have perfect information on enrollees’ health conditions that would be subject to an exemption. There’s not ”a database of whether someone’s, quote, able bodied or not.”
Workers who are self-employed or gig workers also might have a hard time producing documents showing hours worked, these experts said.
Karpman and Haley were co-authors on a March report from the Urban Institute that analyzed a more limited 2023 congressional proposal for work requirements. “Our findings suggest states will disenroll significantly more expansion adults who should be exempt or are already engaged in work activities relative to the disenrollment of adults who are not engaged in work activities and do not meet the exemption criteria,” the report said.
Under the current bill, the expansion population has to renew eligibility at least twice a year, instead of once a year, which could lead to more people losing coverage because they miss notices or don’t file the correct paperwork — or what’s known as procedural disenrollment — not because they aren’t eligible.
This can have a ripple effect, where some children who are eligible could lose coverage when their parents are dropped from Medicaid for failing to complete the renewal process. If parents enroll, they are more likely to get their kids enrolled, and the reverse impact also occurs. “We know that when parents lose coverage, often their children still lose coverage as well,” Tolbert said.
The CBO estimated an increase in the uninsured of 700,000 people in 2034 due to the eligibility redeterminations.
There are a lot of unknowns with how the work requirements could play out, Tolbert said. States have the option to require more frequent eligibility renewals or proof of more than one prior month of work. “State choices here could have significant implications in terms of who is able to meet the requirements or not,” she said.
And federal guidance will come later on specific medical conditions that qualify for an exemption or what documents states will accept.
Other Provisions
While the work requirements are expected to have the largest impact on enrollment, there are other provisions that could lead to lost or reduced coverage.
The bill delays the implementation of some Biden-era rules until 2035. One of those made it easier for seniors or people with disabilities with Medicare coverage who are also eligible for Medicaid to enroll in the latter. In these cases, Medicaid pays for supplemental benefits and Medicare cost-sharing. A preliminary CBO report estimated that 1.3 million in 2034 would lose their Medicaid coverage due to this provision but retain Medicare.
That Biden-era rule also streamlined enrollment and renewals for children and eliminated waiting periods for kids to enroll in the Children’s Health Insurance Program. “The eligibility enrollment rule would fix those problems, and they are repealing that rule,” Cuello said. “So again, that is absolutely going to impact the eligibility of children. Less children will have coverage under the Children’s Health Insurance Program because of those policies.”
The CBO estimated that this provision would increase the number of uninsured by 600,000 in 2034.
Cuello’s center also wrote that the bill prohibits Medicaid payments from going to Planned Parenthood clinics for 10 years, limiting at least some people’s access to care.
And there are the 1.4 million immigrants in the country illegally who CBO estimated would lose coverage through state-only programs. These aren’t Medicaid or CHIP enrollees, but the bill uses Medicaid to pressure states to drop those programs. As we’ve explained, the bill proposes reducing the federal Medicaid match for states’ ACA expansion populations from 90% to 80% if they provide health coverage to people living in the country illegally, regardless of how that program is funded.
According to KFF, there are 14 states, plus Washington, D.C., that have such programs to cover children regardless of immigration status, including seven states and D.C. that also cover some adults.
In addition, the bill increases cost-sharing for expansion enrollees with income above the federal poverty level, adding a $35 co-pay for services, but exempting primary care, and services for mental health or substance use disorders.
Impact on Health Care Providers
Democrats have said that the bill would force health care providers, such as nursing homes, community health centers or rural hospitals, to close. On CNN, Bennet said the legislation would drive “a lot” of health care providers “out of business,” while Warren, in her press conference, said that “hospitals and community health centers” would be “forced to close.” The bill could hurt the finances of these providers, but how many would close their doors as a result is unknown.
Tolbert told us that “it will be hard to say that any hospital closures or other providers going out of business … is directly related to these Medicaid changes.” But there will be financial implications, she said.
Community health centers, for example, are required to provide care regardless of someone’s ability to pay, she said. So centers that see a decrease in their patients’ Medicaid coverage would face increased financial pressure.
Rural hospitals also could be at risk. The bill would prohibit states from increasing or instituting new provider taxes, which states have used to supplement payments to hospitals to cover uncompensated care, Tolbert explained.
Cuello said that some rural hospitals will go bankrupt because of the bill’s provisions. “I can say with a good degree of comfort that if you have, at current level of funding, a lot of hospitals at risk of closure, and you massively decrease funding … we can safely assume that there will be some greater number of hospitals that closes.”
Cuello pointed us to a June report from the Center for Healthcare Quality & Payment Reform that said about a third of rural hospitals in the U.S. “are at risk of closing because of the serious financial problems they are experiencing,” and 14%, or 314 rural hospitals, are “at immediate risk of closing.”
Similarly, Bennet’s and Warren’s offices pointed to the financial frailty of rural hospitals and health centers and how a reduction in Medicaid payments and increased uncompensated care costs would hurt them.
For instance, Warren’s office cited a report from the Urban Institute that estimated that spending for health care services would decline by $771 billion over 10 years due to the bill and uncompensated care costs for the uninsured would go up $198 billion.
The senator’s office also cited comments by Shade Cronan with the Massachusetts League of Community Health Centers, who said the average community health center gets about a third of its revenue from Medicaid. Cronan told New England Public Media in April that the state probably wouldn’t be able to cover a cut in that revenue stream. “And then health centers will have to make really difficult decisions, potentially to reduce services, to close sites, to lay off staff.”
About 19% of hospital care spending in 2023 came from Medicaid, KFF reported, and half of rural hospitals in non-ACA-expansion states and 41% in expansion states had negative margins that year.
All of that shows that a reduction in Medicaid revenue would have a financial impact. But it’s unclear to what extent health care providers would be forced to close because of it and, as Tolbert said, difficult to determine later.
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