Defending Medicaid

WORK REPORTING REQUIREMENTS

Among the many provisions in H.R. 1 that gut Medicaid, one of the most consequential is work reporting requirements (also known as “community engagement” requirements). Beginning January 2027, H.R. 1 requires applicants and enrollees aged 19-64 covered by Medicaid expansion to document they work or participate in “community engagement” activities for at least 80 hours per month, or that they qualify for an exemption (such as having a serious medical condition or being a full-time caregiver). 

The burden of additional paperwork to prove hours worked or various exemptions makes it much harder for working adults, caregivers, and people with disabilities to maintain their Medicaid coverage. Families USA previously broke down why work reporting requirements are a solution in search of a problem, when at least 8 in 10 Medicaid enrollees would meet work or exemption criteria.  

The significant paperwork burden of work reporting requirements along with more frequent eligibility checks means that at least three million and up to 10 million people will lose Medicaid coverage — not because they no longer meet the program’s requirements, but because they cannot jump through administrative hurdles and red tape.

In addition, states now have an enormous task ahead to: (1) set up new systems to determine eligibility and efficiently approve compliance or exemption within a compressed timeline and (2) conduct robust outreach to enrollees about policy changes and what individuals must do to remain covered.

The range of coverage loss in any state will depend on their implementation choices and how well each state can pull together new enrollment systems that adequately determine eligibility and keep vulnerable populations covered. Advocates can make the case for states to continue to learn from past states’ experiences, bolster the Medicaid program and its impact on the state’s health care system, and work closely with a wide range of stakeholders — including Medicaid enrollees and their families, hospitals, community health centers and other Medicaid providers, patient advocacy organizations — to learn about the real, ongoing impacts of implementation decisions.

Advocates Can Impact State Implementation Decisions to Ensure Eligible Populations Stay Enrolled

H.R. 1 offers states several key flexibilities to make operational choices that help reduce the complexity and burden of work reporting requirements, ultimately making it easier for eligible people to obtain and maintain coverage and the state to administer the program. These include:

• Requiring applicants and existing enrollees to show only one month of compliance at application/renewal
• Verifying compliance only at renewal rather than more frequently
• Allowing individuals to self-attest to work or exemptions where possible
• Implementing ex parte (automated) renewal systems
• Strategically engaging impacted communities

While states are awaiting more federal guidance on work reporting requirements (expected by June 2026), states are making important implementation decisions now. For example, states are passing laws to require Medicaid applicants/enrollees to show three months of compliance, verify their compliance more frequently, and limit or prevent self-attestation. In addition, some states — including Nebraska, Montana, and Arkansas — are pushing forward implementation ahead of the already compressed timeline required by H.R. 1. If states rush implementation and make more punitive implementation decisions, Medicaid expansion-eligible communities will have to overcome significantly greater administrative hurdles to achieve and maintain coverage.

State advocates can help raise concerns with state Medicaid officials and other policymakers about rushed implementation and implementation choices that make the already burdensome work reporting requirement process even more challenging for eligible applicants and enrollees.

In addition, advocates can push back against work reporting requirements right now and through 2026, as early implementation begins and as all states head toward a January 2027 start date. We encourage advocates to build the following key moments in the implementation timeline into your advocacy campaigns and partner activations. You can also utilize the resources below, which will be updated throughout the upcoming months.

More Advocacy Resources

• Medicaid Work Reporting Requirements: Bureaucratic Burdens That Threaten Working Families, Providers and Local Economies, Families USA.
• A Guide to Reducing Coverage Losses Through Effective Implementation of Medicaid’s New Work Requirement, CBPP.
• Projected Reductions in Medicaid Expansion Enrollment Under OBBBA’s Work Requirements and Six-Month Redeterminations, Urban Institute.

FACT SHEETS AND ANALYSES

Dangerous Medicaid cuts will result in millions of Americans losing their health care, harming family financial security and devastating state and local economies. These fact sheets delve into a range of topics from populations that rely on Medicaid, the greatest threats faced by the program, and more.

• *NEW* Continued Financial Costs of Mississippi’s Inaction on Medicaid Expansion
• *NEW* Continued Financial Costs of Alabama’s Inaction on Medicaid Expansion
• H.R. 1 – Provisions Section-by-Section Summary and Analysis
• Summary of Harmful Impacts of Trump’s Health Care Cuts
• Senate and House Text Section-by-Section One Big Beautiful Bill Act
• Working America Relies on Medicaid: Congress Must Protect Essential Workers from Devastating Medicaid Cuts
• Federal Medicaid Cuts Would Force Rural Hospitals to the Brink of Closure
• Congress’ Provider Tax Proposals Would Be A Huge Blow to State Budgets
• Harmful Impacts of Proposed House and Senate Budget Bills: What Is at Stake for the 10 States That Have Not Yet Expanded Medicaid
• Medicaid Expansion Reduces Maternal Mortality: Medicaid Cuts Would Be Deadly for Mothers and Babies
• Medicaid Matters: To People, Our Economy and the Health Care System
• Medicaid Work Reporting Requirements: Bureaucratic Burdens That Threaten Working Families, Providers and Local Economies
• Medicaid Cuts Would Rip Away Health Coverage from Millions of Americans, Disproportionately Harming People of Color
• Medicaid Federal Funding: Cuts to Federal Share (“FMAP”) Hurt Families, Providers and State Economies
• Medicaid Provider Taxes: Restricting Them Threatens Hospitals, the Health Care System and State Economies

LOCAL FACT SHEETS

To assist in efforts to Call on Congress following the passage of devastating Medicaid cuts, please utilize our series local fact sheets. We hope the data and talking points included in these fact sheets can be used to apply pressure to target members of Congress — reminding them that the Medicaid program is the bedrock of our health care system and they have a responsibility to their constituents. Should you have any questions about the data, please don’t hesitate to reach out to our team at: governmentrelations@familiesusa.org.

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FEDERAL COMMENTS & STATE-LEVEL TESTIMONY

At the federal level, the Trump administration may take executive action to change existing policy through a notice of proposed rulemaking (NPRM) process or the Centers for Medicare & Medicaid Services (CMS) may provide an open comment period on state 1115 waiver applications following a state comment period (see below). Submitting comments is one way for organizations and individual citizens to provide feedback and create a public record on issues and policies that will impact their families and their communities.

Similarly, at the state level, providing written testimony is one way for organizations and individual citizens to weigh in on the legislative process directly once bills are being heard in a committee after bill introduction. Written testimony (sometimes accompanied by oral testimony provided during the hearing) also provides feedback to legislators and state agency staff and creates a public record on issues that matter to state residents.

Should you have any questions on our submitted comments, state-level testimony or if you are looking for technical assistance to write your own, please reach out to healthpolicy@familiesusa.org.

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Section 1115 State Medicaid Waiver Comment Letters & State-Level Testimony (January 2025 – Present)

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ADDITIONAL RESOURCES

Following the passage of the final budget bill that guts funding for Medicaid, terminates health care coverage for at least 17 million Americans and increases health care costs, it is helpful for researchers, advocates and other stakeholders to have access to the latest research and data on the Medicaid program.

This bibliography of resources pulls together current studies, reports and data analysis that examine: 1) the impact of various proposals to scale back Medicaid; and 2) the value Medicaid brings to the many populations it serves.

The Health Action Resources List is an evolving set of materials to support your work in fighting to defend health care for all Americans, regardless of where they are from, where they work, or how much money they make. Maintained by Families USA and aggregated by national and state partners, this list is a one-stop shop for key information to inform and support your advocacy, across issue areas and resource type.