By Adam Gaffney, M.D., M.P.H.; David U. Himmelstein, M.D.; Danny McCormick, M.D., M.P.H.; and Steffie Woolhandler, M.D., M.P.H.
Health Affairs Forefront, July 2, 2025
The “One Big Beautiful Bill Act” (OBBB) — passed by the House on May 22 and yesterday in the Senate — would make Medicaid coverage for adults contingent on enrollees’ regularly documenting that they are working, are actively seeking work, or qualify for an exemption. The Congressional Budget Office (CBO) estimates that this “work requirement” provision would push 5.2 million people off Medicaid, including many who were already working or should be eligible for exemptions, but who would fail to properly document their circumstances. We and others have projected that those coverage losses would inflict substantial health harms, including thousands of medically-preventable deaths.
Repetitively documenting and monitoring whether Medicaid enrollees have met the work requirements (or are eligible for exemptions) would also require significant administrative expenditures by states’ Medicaid programs — red-tape costs that deserve greater scrutiny as legislation approaches the desk of the President.
Looking Back: Administrative Costs Of Medicaid Work Requirements In 6 States
The first Trump Administration encouraged states to seek Section 1115 Medicaid waivers that would — for the first time in Medicaid history — require enrollees to document work or face disenrollment. CMS ultimately approved 13 states’ applications, although only Arkansas actually disenrolled noncompliant enrollees; disenrollments in other states were stalled either by court orders or the COVID-19 pandemic. Subsequently, the Biden administration rescinded approval of all work-requirement waivers, although a federal court order later reinstated Georgia’s waiver which is now in operation.
These requirements impose new administrative costs on states, which must develop, upgrade, and maintain electronic eligibility and enrollment systems; hire and train staff to process and monitor documentation; and educate beneficiaries. In a 2019 report, the US Government Accountability Office (GAO) assessed the administrative costs associated with implementing (or preparing to implement) work requirements in 5 states: Kentucky, Wisconsin, Indiana, Arkansas, and New Hampshire. Exhibit 1 displays the GAO’s estimates of new administrative costs in each state, the number of beneficiaries subject to work requirements, and our calculations of costs per beneficiary. Administrative spending for implementation ranged from $6.1 million (New Hampshire) to $272 million (Kentucky). Administrative costs per beneficiary subject to work requirements averaged $267, ranging from $84 (in Indiana) to $463 (in Wisconsin). …
Looking Ahead: Work Requirements In The One, Big Beautiful Bill Act And New Section 1115 Waivers
Congress and President Trump look set to impose billions in new bureaucratic costs on Medicaid in order to disenroll 925,000 people not meeting the work requirements, along with 4.3 million others who would likely meet those requirements but be unable to navigate the thicket of red tape required to enroll in or maintain coverage.
Even before the OBBB, the Trump Administration has been approving Section 1115 waivers that would impose work requirements in 3 states, and encouraging waiver applications from other states. Such work requirements will harm the health and finances of millions of low-income Americans, but an even larger share of Americans will pay for the bureaucratic costs needed to operate these programs. …
full analysis: https://healthaffairs.org…