President Donald Trump is expected Friday to sign into law his sprawling domestic policy bill, which includes nearly $1 trillion in cuts to Medicaid, the government health insurance program for low-income and disabled Americans.
Dubbed the “big, beautiful bill,” the new legislation will extend Trump’s 2017 tax cuts and make up for them in part by slashing federal Medicaid funding, introducing copays for some services and — for the first time — implementing nationwide Medicaid work requirements. The final version of the bill didn’t include an estimate of coverage losses; an earlier Congressional Budget Office report projected that about 11 million people could lose their health coverage and become uninsured by 2034 because of the program cuts.
Medicaid is jointly funded by the federal government and the states, which usually mandate that applicants meet certain criteria, such as low income, disability or caregiving status.
Only two states have implemented Medicaid work requirements: Arkansas in 2018 and Georgia in 2023. Georgia’s program, called Pathways to Coverage, remains in effect.
Over the 10 months Arkansas’ work requirement was in place, more than 18,000 people in the state lost Medicaid coverage. Georgia hasn’t done a good job keeping track of how many have lost coverage, but enrollment remains low, said Leighton Ku, director of the Center for Health Policy Research at the Milken Institute School of Public Health at George Washington University.
When people lose Medicaid coverage, they view it as “sort of a slap in the face,” Ku said.
“When your income is down, when you’re unemployed, that’s when you lose everything,” he said. “When you’re most in need. That’s when you lose your food assistance, that’s when you lose your health insurance coverage.”
Kendall Rogers, 40, of Stone Mountain, Georgia, is looking for a job after he lost his Medicaid coverage this year because of the state’s work requirements, according to his mom, Trudy Rogers, 59.
The change means Trudy now has to take care of herself for long parts of the day. She has fibromyalgia and nerve problems in her back that make it difficult for her to get around.
Kendall was caring for her nearly full time, Trudy said, but Georgia’s work requirements don’t offer exemptions for caregivers for older adults.
She called the new requirements “an insult not only to him, but to me.”
“Because now he’s forced to go out and look for work, and I need him to stay around the house,” she said.
Covered in red tape
To justify the cuts, Republicans have argued that they’re not taking Medicaid from those who are rightfully entitled to it — such as, they say, single mothers or the disabled — but from “young, able-bodied men” who they say are abusing the system.
“If you clean that up and shore it up, you save a lot of money, and you return the dignity of work to young men who need to be out working instead of playing video games all day,” House Speaker Mike Johnson, R-La., said in April.
But as seen in Georgia and Arkansas, that’s not who is largely affected.
Cynthia Gibson, director of the Georgia Legal Services Program’s Health Law Unit, which helps appeal Medicaid denials, said many people in the state lose coverage not because they aren’t working, but because they aren’t aware of the new rules or face administrative issues like missed paperwork or not having received notices. Others, like Kendall Rogers, are caring for family members but don’t qualify for exemptions.
Likewise, in Arkansas, only 3% or 4% of the people on Medicaid in 2018 weren’t working and didn’t qualify for the exemptions under the state program, said Dr. Benjamin Sommers, a physician and health economist at Harvard T.H. Chan School of Public Health. Sommers published a study in the New England Journal of Medicine in 2019 looking at the impact of Arkansas’ work requirements.
His research found that about 40% of the other roughly 96% of people on Medicaid in the state were working the required 80 hours a month under the state program. The rest either had medical conditions that prevented them from working or had other responsibilities, such as school or caring for family members.
Implementing work requirements also didn’t result in a higher employment rate — one of the arguments Arkansas officials used in favor of the new work rules.
“Most people, almost everybody, was already doing what [the state] wanted them to do,” he said. Very few were “the proverbial on the couch, video game story that we’re hearing from some of the supporters.”
Most commonly, Gibson said, people aren’t actually aware that they’ve lost coverage until they go see their doctors.
“And that creates kind of a panic,” she said. “Sometimes they may have something really important scheduled that the doctors won’t do when they run their insurance and find out they no longer have coverage.”
Gibson said the people most often affected by the work requirement are those in noncorporate jobs, including independent workers — like Uber drivers or delivery workers — who don’t receive regular pay stubs and can’t meet Georgia’s work verification requirements.
Others include people with certain disabilities that don’t qualify for exemptions, as well as caregivers for children or elderly relatives.
The costs of not having coverage
People who lose coverage often avoid going to the doctor or getting medical care unless it’s an emergency, because they don’t want to accumulate debt, she said.
“They just don’t get treatment; they don’t go to the doctor,” she said.
Heather Payne, 53, of Dalton, Georgia, couldn’t avoid medical care after she had a series of debilitating strokes in 2022.
Unable to work, she was told she didn’t qualify for an Affordable Care Act plan and didn’t qualify for Georgia’s Medicaid program because she was a childless adult.
She later enrolled in classes to become a nurse practitioner — a career she could pursue despite her disability. By that point, the state’s work requirement had gone into effect. However, Payne was told she still didn’t qualify for Medicaid because she wasn’t taking enough credit hours. She couldn’t afford to take more.
To pay for her medical bills, she burned through her $40,000 in savings and is now in collections for tens of thousands of dollars.
“When you have a problem, there’s no help for you,” she said. “It makes you feel as though society doesn’t care what happens to you.”
Dimitris Terrell, 49, of Clarkston, also worries her 24-year-old son, Justin Anderson, could start to accumulate debt following changes to Georgia’s Medicaid program.
Anderson doesn’t work, but he has Medicaid coverage because he has Crohn’s disease, a bowel disease that can cause chronic inflammation of the gastrointestinal tract.
Terrell said her son started having to pay large copays last year, after the state began charging copays for prescription drugs and certain services.
Anderson has paid over $400 out of pocket on doctor’s visits and hundreds of dollars for the dentist, neither of which he could afford, his mother said.
She also worries about his losing coverage — either because he would no longer qualify or because of missed paperwork.
“He’s pretty sad and shocked,” Terrell said. “He said, ‘Like, Mama, I don’t understand why I have to pay.’”
Leave a Reply