Arkansas Proved Medicaid Work Requirements Don't Work. Congress Made Them National Law Anyway.

The Experiment Already Failed

When Arkansas required Medicaid enrollees to report 80 hours of monthly work activity in 2018, 18,000 people lost coverage in seven months. That was one in four people subject to the rule. Employment did not increase at all.

A peer-reviewed study in the New England Journal of Medicine found the requirement produced zero employment gains while driving up the uninsured rate. Among those who lost coverage, 56% delayed care due to cost and 50% took on serious medical debt. A federal judge struck down the policy in 2019.

On July 4, 2025, President Trump signed H.R. 1, the One Big Beautiful Bill Act, which takes the Arkansas model national. Every state must enforce Medicaid work requirements by January 1, 2027.

Who Loses Coverage

The Congressional Budget Office estimates 5.2 million adults will lose Medicaid by 2034. That means roughly one in every 14 current Medicaid expansion enrollees will be dropped, not because they stopped qualifying, but because they could not navigate the paperwork.

Here is the part that makes it worse: 64% of Medicaid adults already work. Another 28% are not working because of caregiving, disability, or school. The requirement does not find unemployed people. It creates a paperwork trap for people who are already doing what the law demands.

“I am insanely worried. It’s made my depression way worse.” — Crystal Schroer, Nebraska Medicaid enrollee, NPR, May 1, 2026

State Implementation Timeline

Nebraska became the first state to enforce the requirements on May 1, 2026. Three states are moving ahead of the federal deadline. The rest must comply by January 2027.

State	Start Date	Status
Nebraska	May 1, 2026	Enforcing now
Montana	July 1, 2026	Implementing early
Iowa	December 1, 2026	Implementing early
Georgia	Has active waiver	Transitioning to federal rules by Jan 2027
All other expansion states	January 1, 2027	Mandatory deadline

43 states total will be required to implement work requirements, including all 41 expansion states plus DC, Georgia, and Wisconsin.

The Cost Nobody Talks About

This is not just a coverage story. The Commonwealth Fund projects hospital operating margins will drop 12.5% to 14.2% nationally when work requirements take full effect. Rural hospitals that already run on thin margins will be hit hardest. Up to 5.6 million community health center patients could lose coverage, threatening $32 billion in health center revenue.

Your state is paying for the bureaucracy to kick people off their insurance. CBPP estimates many states lack the systems to verify work hours and will spend millions building new reporting infrastructure.

What You Can Do

Check your status now. If you are on Medicaid, find out whether your state is implementing early and whether you qualify for an exemption. Do not wait for a letter in the mail.
Contact your state legislators. Tell them to use every available exemption and extension. States can request extensions until December 31, 2028 if they demonstrate good faith implementation efforts.
Call your U.S. representative. Ask them to support repealing the work requirement provisions of H.R. 1. The CBO says this single provision accounts for the largest share of the $911 billion in Medicaid cuts.
Share this with someone on Medicaid. The Nebraska Hospital Association warned that many enrollees do not know these changes are coming.
Follow the tracker. KFF’s implementation tracker monitors each state’s waiver status and policy decisions in real time.

See your state page for local Medicaid details and the Economy hub for the full picture.