On July 4th, President Trump signed the so-called “One Big Beautiful Bill Act” (OBBBA) into law, enacting the most sweeping and harmful Medicaid cuts in history. According to the Congressional Budget Office (CBO), the law slashes $990 billion from Medicaid over the next decade, eliminating Medicaid coverage for at least 10 million people and destabilizing our health care infrastructure. CBO estimates that an additional 4 million people could lose subsidized Marketplace coverage due to OBBBA’s cuts to the Affordable Care Act (ACA).
In this blog post series, NHeLP’s Sexual and Reproductive Health (SRH) Practice Area breaks down how OBBBA will harm SRH care access. This installment addresses how nationwide Medicaid work requirements — OBBBA’s largest Medicaid cut — will gut SRH care access for millions, including:
- What the new work requirements entail;
- How gutting Medicaid expansion via work requirements will hurt SRH service access and outcomes;
- How these losses will harm SRH providers, affecting communities’ access to care regardless of insurance type or status;
- How coverage losses from work requirements and the rest of the federal Medicaid cuts will gut state budgets, potentially leading to state-level Medicaid cuts harming SRH care access; and
- Opportunities for damage mitigation.
OBBBA’s Nationwide Medicaid Work Requirements in a Nutshell
OBBBA ushers in a health care access future that advocates have fought to prevent for years: mandatory nationwide work requirements for Medicaid expansion beneficiaries ages 19 – 64. The requirements will also apply to adults with partial Medicaid expansion coverage under a waiver in states such as Georgia and Wisconsin. States must implement these work requirements by January 1, 2027. They may do so earlier pending approval from the Centers for Medicare and Medicaid Services (CMS), or no later than December 31, 2028 if they request and CMS grants them a one-time extension.
Decades of studies demonstrate that public benefit work requirements do not improve employment outcomes, their purported purpose. Most Medicaid beneficiaries who can work already do so. Instead, work requirements are Medicaid cuts by design, forcing people to overcome a litany of barriers to show that they are already working or qualify for an exemption. To make matters worse, OBBBA locks Medicaid beneficiaries who lose coverage due to work requirements out of subsidized Marketplace coverage and most low-wage workers do not have access to an employer-sponsored plan. CBO estimated that Medicaid work requirements will account for OBBBA’s largest Medicaid cut both in terms of losses of federal funding ($325 billion from 2025 – 2034) and increases to the number of uninsured individuals across the country (an estimated 5.3 million will become uninsured due to this policy).
Under the new Medicaid work requirements, applicable individuals will have to prove that they complete 80 hours of qualifying work-related activities per month[1] or meet exemption criteria in order to enroll in and maintain Medicaid coverage. The law does not permit states to waive (i.e., opt out of) these requirements. Many people will be unable to meet the monthly requirements due to no fault of their own; low-wage workers’ hours are volatile and many face structural barriers to employment. Further, numerous studies on public benefit work requirements show disproportionate sanctions (e.g., termination of benefits) for Black people and people with physical and mental health conditions, suggesting that caseworkers may discriminate based on race, ethnicity, disability, and other protected characteristics under ACA §1557 and other civil rights laws. At a minimum, states must verify qualifying activities or exemptions during the month before application and at least one month between eligibility redeterminations (every 6 months), but OBBBA enables them to implement more frequent and challenging verification requirements.
The law ostensibly exempts certain populations from work requirements, such as people who are eligible for pregnancy related Medicaid coverage; some people with disabilities or chronic conditions; and parents, guardians, or caretaker relatives of disabled individuals or dependent children 13 and under. However, as we have explained elsewhere, nearly three decades of research on and experience with public benefit work requirements have demonstrated that exemptions consistently fail, sparking widespread improper eligibility denials. Exemption processes are notoriously confusing, riddled with complex paperwork and other administrative burdens, and poorly publicized. Applicants and beneficiaries often experience significant power differentials with program caseworkers, who have a great deal of discretion over whether to grant exemptions and often arbitrarily deny them.
Work Requirements Will Gut Medicaid Expansion, an SRH Care Access Lifeline
Medicaid work requirements are Medicaid expansion cuts that will only serve to further decimate access to affordable SRH coverage for people with low incomes and underserved communities. In the 41 states (including D.C.) that have implemented Medicaid expansion, it has profoundly improved SRH care access for millions of people through their reproductive years and thereafter. Dozens of studies demonstrate that Medicaid expansion:
- Increases insurance coverage prior to pregnancy, at birth, and post-pregnancy (e.g., after childbirth, post-abortion);
- Increases access to and utilization of SRH services such as:
- Prenatal, post-pregnancy, and contraceptive care;
- HIV-related services, such as pre-exposure prophylaxis and more timely testing and care linkage;
- Screening, diagnosis, and/or treatment for breast, cervical, endometrial, and ovarian cancers; and
- Care for other SRH-related chronic conditions, such as opioid use disorder during pregnancy; and
- Has played a key role in progress toward ending the U.S. HIV epidemic and maternal mortality epidemic, and narrowing maternal health inequities.
Work Requirements Will Hurt SRH Providers, Undermining Access to Care for All
In recent years, more and more SRH providers, including hundreds of labor and delivery units nationwide, have been forced to shut their doors due to budget shortfalls. Particularly in rural communities, this has meant that people must increasingly drive hours to access pregnancy related care, intensifying the risk of complications. Medicaid expansion has delivered some financial relief, helping rural hospitals and other essential providers keep their doors open to the communities they serve: Medicaid beneficiaries, people with other forms of health insurance, and people who are uninsured alike. Losses of Medicaid expansion coverage from work requirements will undercut this protective effect, driving up SRH care providers’ uncompensated care costs, narrowing their operating margins, and forcing many to shut their doors. OBBBA’s additional Medicaid and ACA cuts will compound these financial harms. The National Partnership for Women and Families recently found that OBBBA’s Medicaid cuts place 131 rural labor and delivery units nationwide at risk of closure or service cutbacks.
Together with Other Medicaid Cuts, Work Requirements May Prompt States to Pursue Cuts to SRH-Related Benefits and Eligibility Categories
Federal Medicaid funding comprises the largest source of federal funding for states, financing just under one-fifth of states’ total spending. The amount of federal Medicaid funding states receive hinges on actual program expenditures: if states cover fewer people, they receive less funding from the federal government. Coverage losses from work requirements and other Medicaid cuts will slash the federal funding that states receive by hundreds of billions of dollars nationwide. States will not be able to fill such a gaping hole in their budgets. Many may pursue state-level Medicaid cuts to make up the difference. For example, they may backslide on Medicaid expansion implementation or drop optional eligibility categories, such as pregnancy related Medicaid coverage extensions, family planning coverage expansions, the Immigrant Children’s Health Improvement Act options to cover lawfully residing immigrants who are pregnant or children, or coverage under the optional Breast and Cervical Cancer Treatment Program. As well, states may drop or place limits on optional benefits such as prescription drugs (critical for a wide range of SRH needs) or doula coverage, or seek waivers of federal protections that help beneficiaries access care.
Conclusion
In recent years, low-income and underserved communities have weathered countless attacks on their SRH. Medicaid work requirements have the potential to further decimate access. NHeLP is committed to working with our partners across the sexual and reproductive health, rights, and justice movement to ensure that this policy change is implemented in the least damaging way possible. Advocates must intervene early, beginning now, to successfully mitigate the damage to come. Opportunities include optimizing redetermination and verification policies and procedures, developing systems for monitoring and evaluating work requirement outcomes and related inequities, notice advocacy, and community outreach. Particularly in the wake of CMS’ illegal release of Medicaid applicant and beneficiaries’ data to the Department of Homeland Security, which houses U.S. Immigration and Customs Enforcement (ICE) (since enjoined in 20 states), Medicaid work requirements, and particularly exemptions (e.g., pregnancy, disability), also raise surveillance concerns. NHeLP is working to monitor and safeguard the privacy of work requirement exemption-related data.
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This blog post is part of a mini-series from NHeLP’s SRH Practice Area delivering our initial analysis on OBBBA’s SRH implications. Preceding installments include:
- OBBBA’s Medicaid Abortion Provider “Defund:” An Overview
- OBBBA’s Unprecedented Attack on Medicaid and the Impact on Access to Sexual and Reproductive Health Care
Access NHeLP’s complete resource library on OBBBA damage mitigation, including subsequent SRH resources, at www.healthlaw.org/prepare/.
[1] Qualifying activities include 80 hours of employment, community service, and/or participation in a work program as defined in the SNAP statute, enrollment as at least a half-time student, or any combination that adds up to at least 80 hours per month. Further, an individual’s monthly income can satisfy the qualifying activity requirement if it is not less than the applicable minimum wage multiplied by 80.
