Work requirements for millions of Medicaid beneficiaries will take effect across the United States in January, and at least six Republican-led states are imposing stricter rules than federal law requires, particularly when people try to prove they are too medically frail to work. The changes stem from President Donald Trump's 2025 tax cut and policy law, which mandates that many lower-income adults report work, volunteering or schooling to keep their health coverage.
The central dispute is how a beneficiary can demonstrate a medical exemption. Federal regulations allow states to accept a recipient's own statement, known as self-attestation, for the first year. But Arkansas, Idaho, Indiana, New Hampshire, North Carolina and Ohio have laws or policies that bar self-attestation for the work requirement exception starting next year, and advocates in other states are pushing to follow. The Congressional Budget Office estimated in 2025 that the changes will save the federal government $887 billion over a decade while leaving 7.5 million fewer people with health insurance.
«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.» That Catch-22 worries patient advocates, who say new applicants in particular may be denied coverage they qualify for because they cannot obtain a doctor's note in time.
The mandate applies to as many as 20 million lower-income adults without children at home who are enrolled through Medicaid's optional expansion in 40 states and the District of Columbia. It does not apply in the 10 states, mostly in the South, that did not expand Medicaid. Beneficiaries must work or volunteer at least 80 hours a month or attend school at least half-time, with exceptions that include medical frailty. The Centers for Medicare and Medicaid Services issued a rule in June saying a person's condition must «significantly impair» their ability to work, volunteer or attend school, a stricter standard than states and providers expected.
Currently states generally review eligibility once a year. The new law requires two reviews for most enrollees. Starting in 2028, states may accept self-attestation only once per enrollment period, after which documentation would be required at least every 12 months to confirm the condition persists and still prevents work. The government expects states to rely increasingly on third-party data such as workers' compensation claims or prescription records. For conditions that do not appear in databases, states can demand a doctor's certification, a disability award letter or other proof.
Democrats in 25 states are suing over the rules, arguing they are too harsh. The conservative Foundation for Government Accountability has urged states not to make it easy to avoid the requirements, saying able-bodied adults are driving up enrollment and costs. «Self-attestation is fraud-by-design,» said Jonathan Ingram, the group's vice president of research and policy. «It is a policy developed by bureaucrats to maximize enrollment at the expense of program integrity.» Self-attestation is made under penalty of perjury, though criminal charges are rare.
Republican Missouri state Rep. Darin Chappell worked with the foundation on a proposed constitutional amendment requiring «documentary evidence» of work or an exemption and specifically prohibiting self-attestation. It passed the Missouri House but died without a Senate vote, and 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.»
States are already straining to implement related changes to the Supplemental Nutrition Assistance Program under the same law. In Arizona, SNAP enrollment fell 55% from April 2025 to April 2026, the largest drop in the country, with more than 400,000 fewer people receiving benefits. State officials attributed the decline largely to difficulties putting new federal requirements in place, which produced higher call volumes and additional verification demands. Many states will also need to spend millions upgrading computer systems before the Medicaid work rules begin.