States Tighten Medicaid Work-Requirement Rules Ahead of 2027 Federal Deadline

The Trump administration’s recent rule allows people who declare themselves “medically frail” to remain on Medicaid through 2027, with verification of that claim slated to begin in 2028. Eight Republican-leaning states—Arkansas, Idaho, Indiana, Iowa, North Carolina, North Dakota, Ohio and Utah—have announced they will require proof of illness earlier, rejecting the one-year grace period. The states plan to enforce work, volunteer or study requirements of at least 80 hours per month for the roughly 21 million people who gained Medicaid coverage under the Affordable Care Act.

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The work-requirement mandate stems from the “One Big Beautiful Bill Act,” passed by Congress last year. The legislation obliges Medicaid enrollees to meet the 80-hour threshold or obtain an exemption for medical frailty. Analysts projected that the rule could cause the loss of at least 5 million Medicaid covers over a decade. Earlier state experiments that permitted “self-attestation” (a sworn statement without a doctor’s note) showed lower loss rates; Arkansas, which kept self-attestation, lost about 29 percent of its Medicaid patients, while New Hampshire’s narrower exemption model projected losses exceeding 40 percent before a court blocked the policy.

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Health-policy consulting firm Manatt Health warns that requiring documentation will burden rural residents, people in provider-shortage areas and those lacking transportation. The Foundation for Government Accountability, funded by GOP megadonors, has spent a decade lobbying for tighter eligibility rules across SNAP, Medicaid and other benefits, and over the past year contracted lobbyists in seven of the eight states now moving to stricter verification.

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Republican Rep. Idaho Democratic Rep. Ilana Rubel warned that the state’s low per-capita provider count will worsen as “tens of thousands more people” are potentially removed from coverage. Ohio’s Medicaid agency said it is working with federal officials to devise a solution for medically frail enrollees who cannot obtain a doctor’s exam.

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• “They sprung into action to put in as many impediments as possible to people remaining on Medicaid,” — Idaho Democratic Rep. Ilana

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• “North Carolina has done what is necessary to comply with federal laws while focusing anew on wasteful spending, fraud and abuse in health care,” — Republican Rep. Donny Lambeth

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These developments illustrate a sharp partisan divide: Democrats and health-care advocates argue that earlier verification will push sick, low-income individuals into uninsured status and strain emergency services, while conservatives contend that stricter enforcement curbs fraud and preserves resources for single parents and disabled beneficiaries.

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