Across the country, millions of people are working long hours, lacing up steel-toed boots, pulling on scrubs, and tying on aprons. They’re cleaning hotel rooms, answering phones, processing meat, driving school buses, filing records, building houses, restocking shelves, and caring for our loved ones. These jobs are hard, physical, often unstable, and low paying. These workers are the backbone of our economy, and in 41 states and the District of Columbia, they have access to health insurance through the Affordable Care Act’s Medicaid expansion.
Before Medicaid expansion, many of these low-wage workers, including many living below and just above the poverty line, were uninsured. They weren’t eligible for traditional Medicaid, which was only available to narrow groups. Their jobs did not provide health benefits. They couldn’t afford private insurance. Medicaid expansion has changed and saved lives, extending health insurance that helps keep people healthy so they can work, fights the U.S. maternal mortality epidemic, and ensures people with disabilities can access the care they need to continue living at home and in their communities, rather than in institutions.
Yet instead of supporting hardworking individuals trying to make ends meet, Congressional Republicans’ so-called “One Big Beautiful Bill” would scapegoat and punish them. The bill includes a Medicaid “work requirement” — a misnomer since research shows that the vast majority of Medicaid enrollees who are able to work already do. The work requirements would end health insurance coverage for between roughly 5 and 7 million people. Together, the bill’s anti-health policies would result in 16 million people losing health insurance nationwide.
The proposal would require states to deny Medicaid coverage unless a person can prove they are working, even before they enroll. If you’re a home care aide between jobs, a health care worker whose hours got cut, a retail worker who is having trouble finding steady employment, or a warehouse worker recovering from surgery, this bill slams the door in your face. No job? No coverage. Sick? Too bad. In a new national Gallup survey of U.S. workers, 41% said they have little or no control over how many hours they work and more than a quarter said they do not know their schedule two weeks or more in advance. These rates are likely much higher for low-wage workers.
It gets worse. States could require people to report work activity every single month. So if you’re a gig worker or shift worker whose manager changes your schedule; a seasonal worker, such as a school bus driver; or miss a week or two of work because of illness or a family emergency, you could lose your health insurance. And you wouldn’t just lose Medicaid: the bill would also bar you from discounted health care through the Marketplace. Work requirements simply don’t account for the economic realities of the 21st century.
The work requirement proposal gets it backward. Medicaid expansion helps low-wage workers stay employed and students complete their education. Without health care, people are more likely to fall further behind, miss more work, and eventually drop out of the job market or school altogether. We’ve seen this play out before. When a similar policy was implemented in Arkansas in 2018, over 18,000 people – about one in four people subject to the work requirement – lost coverage. Employment didn’t go up, but hardship and poor health did. NHeLP and our partners went to court and stopped Arkansas’ work requirements, and blocked them in 11 other states.
Further, decades of research on work requirements in public benefits programs shows that exemptions for those who cannot work based on disability, pregnancy, caregiving, age, or other factors consistently fail. Exemption processes are notoriously confusing, poorly publicized, and riddled with paperwork and red tape. In Arkansas, many people with disabilities or other serious health issues still lost coverage because the exemption process was so broken. The complexity isn’t a flaw; it’s the point. And the bill’s work requirements would be worse than Arkansas’; they are the most extreme we have ever seen.
The list of harms goes on. Work requirements punish older adults who can no longer work the way they used to, but who haven’t yet aged into Medicare. Domestic violence survivors will be forced to work when it’s not safe. There’s no protection for people who experience pregnancy loss. States would not have to provide leniency for people transitioning between health care settings or who experience a sudden health emergency. There’s no grace period for someone who gets sick and is unable to file paperwork. States could require people to prove they’ve worked for months or even years before they’re allowed to apply for coverage in the first place. Miss a month, and the clock resets.
Medicaid is a lifeline, sometimes a long-term lifeline, for people trying to survive in an unjust economy. It helps level the playing field. That’s why the vast majority of people across the political spectrum want Congress to strengthen Medicaid, not cut it. Despite political divides, most of us agree that the working-class deserves better. They don’t need more red tape. They don’t need constant government scrutiny. Members of Congress need only listen to their constituents to understand the real solutions to employment barriers. People need access to health care, child care, nourishing food, public transportation, and jobs with fair pay and predictable hours, not Medicaid cuts.
Medicaid work requirements are Medicaid cuts and a direct attack on working families. Congress knows their proposal will trip people up and blame them for falling, devastating their health insurance access, and widening U.S. wealth inequality. These are features, not bugs, of their reconciliation bill. We, the people, must demand policies that truly support the working-class. Protecting Medicaid is a critical first step.
