Investigative Report · October 25, 2026
Medicaid Work Requirements:
The Paperwork Test
Medicaid’s work requirement arrives January 1, 2027. The early evidence shows the real test is paperwork, not work.
Overview
A work test, or a paperwork test?
On January 1, 2027, adults covered through the Affordable Care Act’s Medicaid expansion in 40 states and the District of Columbia, plus certain waiver enrollees in Georgia and Wisconsin, must show 80 hours a month of work, school, job training, or community service, or show that they qualify for an exemption, to get or keep coverage. Nebraska, the first state to enforce the new federal rules, offers the first real data. Losses were smaller than many feared. But almost none of the people who lost coverage were found to be avoiding work. They lost coverage because a form was not returned.
92%
of Nebraska’s work requirement losses at renewal came from unanswered verification requests
KFF, Sept 2026
64%
of adult Medicaid enrollees ages 19 to 64 were already working; 92% were working or had a barrier to work
KFF, 2023 data
18.5M
people CBO estimates will be subject to the requirement each year
CBO via KFF
68
days from publication to the national January 1 deadline
Live countdown
Where 7,280 Nebraska renewals went
Renewals subject to the work requirement, July to mid-August 2026
7,280
Renewals needing a work requirement decision
6,747
Kept coverage: 57% excluded, 34% met an activity, 2% hardship exception
533
Lost coverage
about 490
Did not return requested information (92%)
about 43
Affirmatively found noncompliant (8%)
Source: KFF analysis of Nebraska DHHS Medicaid Advisory Committee data, September 29, 2026. Kept-coverage count is total minus losses; the 490 and 43 split is author-derived from the published 92% and 8%.
The central finding
When the state could confirm work or exemption from its own data, people kept coverage. When it had to ask, more than nine in ten of the people who lost coverage were lost to the asking, not to a finding that they were not working.
Eight key findings
Documentation is being measured as much as employment. Of 533 Nebraskans who lost coverage at renewal, 92% did not respond to verification requests. Among 557 denied applicants, 84% were denied for nonresponse.
Most people subject to the rule already work or qualify for an exemption. 64% of adult enrollees work; 92% work or are caregiving, ill or disabled, or in school.
The size of the loss is contested. CMS projects 2.3 million fewer enrollees in FY2027; CBO 5.2 million by 2034; the Urban Institute 5.5 to 6.3 million at full implementation.
Earlier experiments removed people without raising employment. Arkansas removed more than 18,000 adults with no employment gain; Georgia spent twice as much on administration as on care.
There is no off-ramp. People who lose Medicaid for noncompliance are ineligible for ACA premium tax credits.
The federal rule is stricter than many states planned for. It narrows medical frailty, limits self-attestation after 2027, and restricts claims lookback to 12 months.
Hospitals and clinics absorb what coverage no longer pays. Hospital margins in expansion states are projected to fall 11.7% to 13.3%, and 25.9% to 29.6% at safety-net hospitals.
Readiness, not intent, will decide outcomes. The national median share of renewals left pending rose for three straight quarters before enforcement began.
The source report
The Paperwork Test: Medicaid’s Work Requirement Arrives January 1, 2027
This dashboard is built from Kelly Emrick’s 23-page investigative report, a structured synthesis of the statute and the June 2026 CMS interim final rule, federal and independent projections, peer-reviewed research on Arkansas, government audit findings on Georgia, Nebraska’s first administrative data, and analyses from KFF, Georgetown University, the Commonwealth Fund, Brookings, and others. The report does not take a position on whether work requirements are good policy; it examines how they are being implemented and what the evidence shows about who loses coverage and why.
Use the tabs above to explore the rule, the projections, the state evidence, the verification path, and a revenue-at-risk model for your organization.
The Rule
What the law and the June 2026 rule require
The 2025 budget reconciliation law sets the frame. CMS filled in the operating details through an interim final rule issued June 1, 2026 and effective July 31, 2026. Because Congress directed an interim final rule, the agency did not have to complete notice-and-comment rulemaking before enforcement began.
Who is subject
Nonpregnant adults ages 19 to 64 in the ACA expansion group and certain Section 1115 waiver groups, not enrolled in Medicare.
Monthly standard
80 hours of work, community service, a work program, or a combination; half-time school; or monthly income of at least $580 (80 times the federal minimum wage).
Look-back at application
Applicants show compliance for one to three consecutive months before applying, at state option.
Verification order
States check exclusions and data they already hold first. If they cannot verify, they send a notice and the person has 30 days to respond.
Self-attestation
Accepted through 2027. From January 2028, documentation is generally required when the state lacks data, with special limits for medical frailty.
Renewals
Every six months for expansion adults; states may check compliance more often.
Optional hardship exceptions
Hospitalization, travel for care, disasters, high county unemployment. 29 states planned at least one; Missouri declined them.
Consequence
Denial or disenrollment, plus ineligibility for ACA marketplace premium tax credits. There is no subsidized fallback.
Deadlines and money
Implement by January 1, 2027; good-faith extensions possible through December 31, 2028. $200 million to states versus a CMS systems estimate of about $660 million.
Mandatory exclusions
States must check these before evaluating work
- Pregnant or postpartum
- American Indian or Alaska Native
- Parent or caretaker of a child under 14
- Caregiver of a person with a disability
- Veteran with a total disability rating
- Medically frail
- Meeting SNAP or TANF work rules
- Recently incarcerated
Sources: KFF; MACPAC September 2026 overview of CMS-2454-IFC.
From law to deadline
Status updates automatically from today’s date
- Jul 4, 2025Law signed
- Dec 8, 2025First CMS guidance to states
- May 1, 2026Nebraska begins enforcement
- Jun 1, 2026CMS interim final rule
- Jun 29, 2026States sue over the rule
- Jul 1, 2026Montana begins; Arkansas soft launch
- Late Jul 2026Preliminary injunction denied
- Oct 1, 2026Montana enforces; five governors seek delay
- Nov 1, 2026ACA open enrollment opens
- Dec 1, 2026Iowa begins with new applicants
- Jan 1, 2027National deadline
- Dec 31, 2028Latest possible state extension
Sources: CHCS; KFF; NPR; Arkansas DHS; Iowa HHS; Georgetown Law Litigation Tracker; Healthcare Dive.
Two design choices that drive everything else
First, verification runs in a fixed order: exclusions and data matches before anything is asked of the person. When that automated step works, most people never see a form. When it fails, the burden shifts to the enrollee, who has 30 days to respond. Second, the consequences extend beyond Medicaid. A person who loses coverage for noncompliance cannot buy subsidized marketplace coverage, which removes the safety valve that cushioned earlier coverage losses. Try both on the tab.
The Numbers
Three projections, one argument
Every major projection agrees that coverage will fall. They disagree, sometimes sharply, about how much and why. The gap is not arithmetic. It is a disagreement about human behavior: whether people will start working, or simply lose coverage.
How many people will lose coverage?
Projected coverage effects by source and horizon, millions of people
Interactive chart loads with JavaScript. The published figure is available below.
View the published figure
Sources: CMS regulatory impact analysis as summarized by Applied Policy; CBO as reported by FactCheck.org; Urban Institute estimates as reported by the Commonwealth Fund.
| Source | Estimate | Key assumption |
|---|---|---|
| CBO (2025) | 5.2M fewer enrollees; 4.8M more uninsured by 2034 | Little employment response; disenrolled people barred from subsidies |
| CMS rule (2026) | 2.3M fewer in FY2027; 3.1M to 3.3M per year after | 15% disenrollment; about one-third of affected adults become engaged |
| Urban Institute (2025) | 5.5M to 6.3M lose coverage | Noncompliance rates observed in Arkansas and New Hampshire |
Planned versus observed: why people lose coverage
Percentage points of the affected population
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CMS plans for 15% disenrollment: 9 points from people not meeting the requirement and 6 points from paperwork barriers, so about 60% of losses are substantive. In Nebraska’s renewals, 7% lost coverage and only 8% of those losses were substantive, about 0.6 points; roughly 6.4 points were procedural.
Sources: Holland & Knight summary of the CMS regulatory impact analysis; KFF Nebraska analysis. Nebraska point split is author-derived from published percentages.
The critique of the federal estimate
CMS’s smaller coverage loss rests on an assumption that roughly one-third of affected people will become newly engaged in work or other activities. Richard Frank of Brookings argues this is more than six times the largest estimate in the research literature, and notes CMS projects larger federal savings than CBO despite a smaller coverage loss. The Urban Institute’s formal comment reached a similar conclusion.
CMS projects $350.3 billion in federal and $41.6 billion in state savings over 10 years, and up to 4.4 million people meeting the requirement.
How to plan
Treat the projections as a range. Budget for the higher estimates while tracking the early state data, which will show within months which assumptions are closer to reality. Model your own exposure on the tab.
The Evidence
Four states, one pattern
Every state that has tried a Medicaid work requirement has produced the same signal: coverage falls mostly because of process, while employment does not measurably rise. Select a state.
Nebraska: first under the new federal rules
Nebraska applied the requirement to new applicants on May 1, 2026 and to renewing enrollees on July 1. Advocates reported the state hired no new staff and added no technology funding. A health center association that usually enrolls about 15 people a month enrolled none in May.
Of 7,280 renewals subject to the requirement, 93% kept coverage. Of the 533 who lost it, 92% had not responded to verification requests. Of 4,089 applications needing a decision, 14% were denied, and 84% of those denials were for nonresponse.
Two cautions. 4,434 more applications were denied for reasons the state classified as unrelated, and Georgetown’s Joan Alker estimates more than half of new applicants (52%) are now denied. Nebraska has also accepted self-attestation and operated before the stricter frailty standard; CMS has told the state to change its frailty process.
93%
of renewals kept coverage
92%
of renewal losses were nonresponse
39%
of renewal exclusions were medically frail
97%
of those meeting activities did so through work hours or the $580 income test
Outcomes for people subject to the rule
May to mid-August 2026
Interactive chart loads with JavaScript.
View the published figure
Source: KFF analysis of Nebraska DHHS data, September 29, 2026. Applicant shares sum to 101% because of rounding.
Why people lost coverage
Share of denials and disenrollments by reason
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View the published figure
Source: KFF analysis of Nebraska DHHS data, September 29, 2026.
Georgia Pathways: the longest-running program
Georgia’s Pathways to Coverage, the only work requirement operating before the federal mandate, covers adults up to the poverty line who document qualifying hours. The state projected 25,000 enrollees in year one. After two years, about 8,077 were enrolled as of June 2025.
A GAO review found Georgia reported $54.2 million in administrative spending and $26.2 million in health care spending from fiscal 2021 through the second quarter of fiscal 2025, with nearly 90% of administrative costs paid by federal taxpayers. The administrative share fell from 96.5% in fiscal 2023 to 58.8% in fiscal 2024. The Georgia Budget and Policy Institute puts total costs since approval at $165.7 million, about $8,945 per active enrollee.
$54.2M
administration versus $26.2M health care (GAO)
8,077
enrolled June 2025 versus 25,000 projected
$8,945
total cost per active enrollee since approval
46%
of all program spending went to administration
Spending and enrollment
Two separate measures shown side by side, each on its own scale
Interactive chart loads with JavaScript.
View the published figure
Sources: GAO as reported by The Current and North Carolina Health News; Emory Rollins School of Public Health; Georgia Budget and Policy Institute.
Arkansas 2018: the first test
Arkansas became the first state to implement a Medicaid work requirement in June 2018, with monthly online reporting. By the time a federal judge halted it in 2019, more than 18,000 adults had lost coverage.
Peer-reviewed research led by Benjamin Sommers found no change in employment and a rise in the uninsured rate among adults ages 30 to 49, from 10.5% in 2016 to 14.5% in 2018. Two-year follow-up found most losses reversed after the court order, employment did not rise over 18 months, and the policy was associated with more medical debt.
Uninsured rate, Arkansans ages 30 to 49
Before and during the work requirement
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Sources: Sommers et al., NEJM 2019 and Health Affairs 2020, via Becker’s and Policies for Action.
Montana: enforcement began October 1
Montana applied the requirement to nearly 71,000 expansion adults on July 1, 2026 with a three-month grace period, then began denying and disenrolling on October 1. A Montana Healthcare Foundation estimate suggests about 29,000 people could lose coverage. The state enters the policy with Medicaid enrollment already at its lowest point in about a decade after pandemic-era redeterminations.
71,000
adults subject (nearly)
29,000
could lose coverage (foundation estimate)
Arkansas, 2026
Soft launch July 1 using wage data, other program data, and medical claims to classify enrollees and send status notices. No coverage losses until January 1, 2027.
Iowa
New applicants on December 1, 2026; current Iowa Health and Wellness Plan members at renewals beginning in early 2027.
Missouri
344,669 expansion adults (September 2026). Starts January 1, 2027; declined optional hardship exceptions; renewed 52.3% ex parte in Q1 2026.
| State | Start | Population or scale | Status and notes |
|---|---|---|---|
| Georgia | July 2023 | About 8,077 enrolled (June 2025) | Longest-running program; coverage to 100% of poverty |
| Nebraska | May 1, 2026 | About 70,000 expansion adults | At least 1,090 lost or denied through August |
| Montana | July 1, 2026; enforcement Oct 1 | Nearly 71,000 subject | About 29,000 could lose coverage (estimate) |
| Arkansas | July 1, 2026 soft launch | ARHOME expansion adults | Penalties begin January 1, 2027 |
| Iowa | December 1, 2026 | Health and Wellness Plan members | Applicants first; members at renewal in 2027 |
| Missouri | January 1, 2027 | 344,669 expansion adults | Declined optional hardship exceptions |
| Other expansion states | January 1, 2027 | Varies | Five governors seek delay; none reported approved as of early October |
Sources: Emory; Nebraska Hospital Association; Georgetown CCF; NPR; Arkansas DHS; Iowa HHS; Missouri Independent; Healthcare Dive.
Paperwork Path
Follow one enrollee through verification
The federal rule fixes the order of verification. Set a person’s real situation and what the state’s data can see, and watch where they end up. The pattern Nebraska revealed appears quickly: a working or exempt person can lose coverage at the third step.
1. What is this person’s real situation?
2. Does state data already show the exclusion?
For example, a dependent child under 14 on the case, or claims in the last 12 months showing a qualifying condition.
3. Does state data confirm the work?
Quarterly wage records, SNAP data, or income of at least $580 a month. Gig work, cash jobs, and variable hours often do not show.
4. If a notice is mailed, does the person respond within 30 days?
Notices go to the address on file. Moves, shift work, and unclear letters are common reasons for no response.
5. Which year?
- 1
Exclusion check from state data
Not shown in data
Nebraska renewals: 57% excluded here
- 2
Work or income match from state data
Not confirmed
Nebraska renewals: 34% met an activity
- 3
Notice mailed: 30 days to respond
No response
Nebraska renewals: 7% lost here; 92% of them by nonresponse
Coverage lost: procedural
Working, but uninsured anyway
This person meets the requirement, but the state’s data could not see it and the notice went unanswered. This is the most common way coverage was lost in Nebraska, and the person is also barred from subsidized marketplace coverage.
Logic follows the verification order in CMS-2454-IFC as summarized by KFF and MACPAC. Nebraska shares are for renewals, July to mid-August 2026 (KFF). The simulator is illustrative and does not model optional hardship exceptions.
Revenue at Risk
What the work requirement could cost your organization
This model applies the report’s transparent formula. The default inputs reproduce the report’s illustration exactly: 10,000 expansion-group patients at a 7% to 15% loss rate place $1,288,000 to $2,760,000 of annual revenue at risk. Replace every input with your own figures.
Adults 19 to 64 covered through Medicaid expansion in your payer file.
Use 100% to match the report, or lower it if you can identify excluded patients.
$2,000 is a hypothetical placeholder from the report.
8% reflects CBO’s assumption that about 92% of people who lose coverage become uninsured.
Optional: uncompensated care for patients who keep coming
Your own assumptions. Both default to zero so the base result matches the report.
Optional: the Double Hit, adding ACA marketplace attrition
Paid marketplace enrollment fell about 12% from February 2025 (21.8M) to February 2026 (19.2M).
Patients losing Medicaid
700
Of whom become uninsured
644
Annual revenue at risk
$1,288,000
Added uncompensated care
$0
Marketplace attrition exposure
$0
Total annual exposure
$1,288,000
10,000 patients × 100% subject × 7% loss × $2,000 × (1 minus 8%) = $1,288,000
Scenario comparison
Annual revenue at risk at each loss rate, with your other inputs held constant
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How the loss could build through 2027
Monthly revenue at risk if six-month renewals are spread evenly from January to June
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Under this illustrative timing, the full annual run rate is reached in June, and 2027 realized revenue at risk is $1,019,667, about 79% of the annual figure. Actual timing depends on your state’s renewal calendar.
| Loss rate | Patients losing Medicaid | Become uninsured | Annual revenue at risk |
|---|---|---|---|
| 7% | 700 | 644 | $1,288,000 |
Formula: annual revenue at risk = patients × share subject × loss rate × revenue per patient × (1 minus share finding other coverage). Loss-rate anchors: Nebraska renewals (KFF, Sept 2026) and the CMS planning assumption (Holland & Knight summary of the regulatory impact analysis). Illustrative only; not financial advice.
Providers & Imaging
Who absorbs what coverage no longer pays
Coverage losses do not end the need for care. They shift it to emergency departments, safety-net hospitals, and community clinics, and they arrive alongside falling marketplace enrollment, six-month renewals, and shorter retroactive coverage in the first quarter of 2027.
Projected hit to hospital finances
Relative decline once fully implemented, 2,958 hospitals in expansion states
Interactive chart loads with JavaScript.
View the published figure
Source: Haught R, et al., Commonwealth Fund, September 2025. Rural safety-net figure is net operating income; the others are operating margin.
$12.2B to $13.8B
less Medicaid revenue for hospitals
$7.0B to $8.0B
more uncompensated care, up 29.5% to 33.6%
5.6M
health center patients who could lose Medicaid over five years
Up to $32B
in health center revenue losses over five years
43%
of hospitals already operating in the red in 2026
300+
rural hospitals the AHA says are at risk under the law’s Medicaid cuts
The imaging and outpatient diagnostics exposure
For scheduled services, the risk is timing. A study booked weeks ahead may reach a patient who was eligible at scheduling and is not eligible on the day of the scan, and shorter retroactive coverage limits recovery after the fact.
Verify closer to service
One check at scheduling is no longer enough for expansion-group patients. Add a second check within a few days of the appointment.
Talk about cost earlier
Patients flagged at risk should get a good-faith estimate and financial counseling before the exam, not a bill afterward.
Code completely
States use recent claims to grant frailty exclusions without paperwork, so complete diagnosis coding protects coverage.
Treat reminders as care
Schedulers are often the last staff to see a patient before coverage lapses. A short prompt about the 30-day window can prevent a loss.
Readiness checklist: the next 68 days
Choose your role and check off what is done. Progress is saved in this browser only.
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The Debate
The case for work requirements, and the evidence test
A fair investigation states the strongest version of the argument for the policy. It is held sincerely, and by a majority of the public when the question is first asked.
What supporters argue
- Protect finite resources. The Paragon Health Institute argues the requirements reserve Medicaid for people who cannot work because of disability, frailty, or caregiving, while promoting independence for those who can.
- Work builds well-being. Supporters hold that work is essential to economic opportunity and long-term flourishing.
- Verification matters. Relying on self-attestation alone, particularly for medical frailty, risks improper enrollment.
- The federal match is higher for expansion adults. Washington pays a much larger share for this group than for children, seniors, or people with disabilities.
- CMS expects engagement. The agency projects up to 4.4 million people will meet the requirement, with improved economic and health outcomes. Supporters also cite 1990s welfare reform.
What the evidence shows so far
- Arkansas: more than 18,000 lost coverage with no measurable employment gain.
- Georgia: about 8,077 enrolled against 25,000 projected, with administration costing more than twice what care did through early fiscal 2025.
- Nebraska: 92% of renewal losses were procedural, not findings of noncompliance.
- The federal estimate: critics at Brookings and the Urban Institute argue CMS’s employment assumption is far above the research literature.
Public support depends on which facts people hear
Share of adults who favor Medicaid work requirements, KFF Health Tracking Poll. Select a framing.
Interactive chart loads with JavaScript.
About six in ten adults (62%) initially favor requiring nearly all adults to work or look for work to receive Medicaid.
View the published figure
Source: KFF Health Tracking Poll (2025). A 2026 Montana Free Press poll found 59% of Montana voters supported the requirements.
A fair reading
Both sides say the policy should reach adults who can work and are not, while protecting people who work, care for others, or are too sick to work. The disagreement is empirical: whether reporting systems can find the first group without removing the second. The early data will answer that faster than the debate will.
Watch List & Sources
Indicators that will settle the question
The coming months will show which projections were right. These indicators, most of them public, will reveal whether the requirement is working as a work test or a paperwork test.
| Indicator | Why it matters |
|---|---|
| Procedural share of coverage losses | If most losses stay procedural, the policy is removing eligible people; Nebraska’s renewal figure is 92% |
| Ex parte renewal rate by state | The strongest predictor of whether eligible people keep coverage without paperwork |
| New applicant denial rate | Shows whether the policy blocks entry, not only exits |
| Reenrollment within 90 days | High reenrollment signals people were eligible all along |
| Pending renewals and call center wait times | Early signs of administrative overload; the national median pending share rose from 4.3% to 7.0% over three quarters |
| Frailty exclusion share after 2027 | Will reveal the effect of documentation requirements and the narrowed definition |
| Hospital self-pay and uncompensated care | The downstream financial signal for providers |
| Massachusetts v. Oz and HHS extension decisions | Could change the frailty rules or the timeline |
A system under strain before the clock starts
National median share of Medicaid and CHIP renewals left pending
Interactive chart loads with JavaScript.
View the published figure
Source: Georgetown University Center for Children and Families H.R. 1 Readiness Tracker, August 2026.
Methods and limitations
This dashboard reproduces the findings of a structured synthesis of the statute and CMS-2454-IFC as summarized by legal and policy analysts; projections from CBO, CMS, and the Urban Institute; peer-reviewed research on Arkansas; GAO findings on Georgia; Nebraska administrative data presented in September 2026; state agency announcements; and analyses from KFF, Georgetown, the Commonwealth Fund, Brookings, and others. Sources were accessed through October 25, 2026.
Nebraska’s data covers only the first months, under self-attestation and before the tightened frailty rules, and may not predict larger or less prepared states. Projections differ because of assumptions about behavior and implementation. Hospital modeling assumes full implementation in 2027. Some state figures come from news reports of state data. The revenue model uses hypothetical defaults for illustration. Nothing here is legal or financial advice.
References
- 1.Center for Health Care Strategies. A Summary of Federal Medicaid Work Requirements. 2026. https://www.chcs.org/resource/a-summary-of-national-medicaid-work-requirements/Research and policy
- 2.Diana A, Mudumala A, Tolbert J. Early Medicaid Work Requirement Insights From Nebraska. KFF; September 29, 2026. https://www.kff.org/medicaid/early-medicaid-work-requirement-insights-from-nebraska/Research and policy
- 3.Commonwealth Fund. More ACA Premium Spikes to Come in 2027 Amid Federal Policy Changes. October 2026. https://www.commonwealthfund.org/blog/2026/more-aca-premium-spikes-come-2027-amid-federal-policy-changesResearch and policy
- 4.KFF Health News. Shopping for an ACA Plan This Year? Here's What You Need To Know. October 23, 2026. https://kffhealthnews.org/insurance/aca-obamacare-open-enrollment-marketplace-shopping-tips-premiums-costs-cms-changes/News and industry
- 5.Alker J. What do Results from First State to Impose Medicaid Work Mandate Reveal? Georgetown University Center for Children and Families; September 30, 2026. https://ccf.georgetown.edu/2026/09/30/nebraska-releases-first-data-on-medicaid-work-reporting-requirement-as-expected-coverage-losses-start-to-mount-due-to-red-tape/Research and policy
- 6.KFF. Understanding the Intersection of Medicaid and Work: An Update. 2026. https://www.kff.org/medicaid/understanding-the-intersection-of-medicaid-and-work-an-update/Research and policy
- 7.Applied Policy. CMS Issues Interim Final Rule on Medicaid Community Engagement Requirements. August 2026. https://www.appliedpolicy.com/cms-issues-interim-final-rule-on-medicaid-community-engagement-requirements/Official and legal
- 8.FactCheck.org. Assessing Medicaid Coverage Losses Under House Reconciliation Bill. June 2025. https://www.factcheck.org/2025/06/assessing-medicaid-coverage-losses-under-house-reconciliation-bill/News and industry
- 9.Haught R, et al. The Impact of Proposed Federal Medicaid Work Requirements on Hospital Revenues and Financial Margins. Commonwealth Fund; September 2025. https://www.commonwealthfund.org/publications/issue-briefs/2025/sep/impact-medicaid-work-requirements-hospital-revenues-marginsResearch and policy
- 10.Policies for Action. Consequences of Work Requirements in Arkansas: Two-Year Impacts on Coverage, Employment, and Affordability of Care (Sommers BD, et al., Health Affairs, 2020). https://policiesforaction.org/evidence/consequences-work-requirements-arkansas-two-year-impacts-coverage-employment-andResearch and policy
- 11.Coker M. Georgia's Medicaid work requirement program spent twice as much on administrative costs as on health care, GAO says. The Current, republished by North Carolina Health News; September 2025. https://www.northcarolinahealthnews.org/2025/09/27/georgias-medicaid-work-requirement-program-spent-twice-as-much-on-administrative-costs-as-on-health-care-gao-says/News and industry
- 12.KFF. A Closer Look at the Work Requirement Provisions in the 2025 Federal Budget Reconciliation Law. 2025. https://www.kff.org/60c1aadResearch and policy
- 13.Georgetown Law. Commonwealth of Massachusetts et al. v. Oz et al. Health Care Litigation Tracker. 2026. https://litigationtracker.law.georgetown.edu/litigation/commonwealth-of-massachusetts-et-al-v-oz-et-al/Official and legal
- 14.Healthcare Dive. Governors ask HHS for more time to implement Medicaid work requirements. October 2, 2026. https://www.healthcaredive.com/news/medicaid-work-requirements-governors-ask-hhs-delay-letter/831992/News and industry
- 15.Rosenbaum S, Jacobs F, Johnson K. Nearly 5.6 Million Community Health Center Patients Could Lose Medicaid Coverage Under New Work Requirements, with Revenue Losses Up to $32 Billion. Commonwealth Fund; May 30, 2025. https://www.commonwealthfund.org/blog/2025/community-health-center-patients-medicaid-coverage-work-requirementsResearch and policy
- 16.Georgetown University Center for Children and Families. H.R. 1 Readiness Tracker Update: Strain Is Building Before the Work Reporting Requirements Clock Starts. August 24, 2026. https://ccf.georgetown.edu/2026/08/24/h-r-1-readiness-tracker-update-strain-is-building-before-the-work-reporting-requirements-clock-starts/Research and policy
- 17.NPR. Montana starts enforcing Medicaid work requirements on Oct 1. Patients are confused. September 30, 2026. https://www.npr.org/2026/09/30/nx-s1-5946766/montana-early-medicaid-work-requirements-patients-confusedNews and industry
- 18.Arkansas Department of Human Services. DHS to launch soft implementation of work and community engagement requirement starting July 1. February 23, 2026. https://humanservices.arkansas.gov/news/dhs-to-launch-soft-implementation-of-work-and-community-engagement-requirement-starting-july-1/Official and legal
- 19.Iowa Department of Health and Human Services. IHAWP Community Engagement Requirements. 2026. https://hhs.iowa.gov/medicaid/plans-programs/iowa-health-wellness-plan/ihawp-community-engagement-requirementsOfficial and legal
- 20.Foley Hoag. CMS Issues Interim Final Rule Imposing Medicaid Work Requirements for Expansion Populations. June 2026. https://foleyhoag.com/news-and-insights/publications/alerts-and-updates/2026/june/cms-issues-interim-final-rule-imposing-medicaid-work-requirements-for-expansion-populations/Official and legal
- 21.Medicaid and CHIP Payment and Access Commission. Community Engagement Requirements in Medicaid: Overview of Interim Final Rule (September 2026 meeting slides). https://www.macpac.gov/wp-content/uploads/2026/09/01_September-Slides-Community-Engagement-Requirements-in-Medicaid.pdfOfficial and legal
- 22.PBS NewsHour. As states face stricter Medicaid work requirements, Nebraska is an early test. June 5, 2026. https://www.pbs.org/newshour/nation/as-states-face-stricter-medicaid-work-requirements-nebraska-is-an-early-testNews and industry
- 23.Healthcare Dive. How states are planning to implement Medicaid work requirements: survey. May 2026. https://www.healthcaredive.com/news/state-medicaid-work-requirements-implementation-decisions-kff-georgetown-center-children-families/819013/News and industry
- 24.American Association of Psychiatric Pharmacists. CBO Affirms 10 Million Are Projected to Lose Coverage. August 2025. https://aapp.org/node/800008Research and policy
- 25.Holland & Knight. CMS Issues Interim Final Rule Implementing Medicaid Community Engagement Requirements. June 2026. https://www.hklaw.com/en/insights/publications/2026/06/cms-issues-interim-final-rule-implementing-medicaid-communityOfficial and legal
- 26.Frank RG. Medicaid work requirements built on invented evidence will harm the people they claim to help. Brookings Institution; August 2026. https://www.brookings.edu/articles/medicaid-work-requirements-built-on-invented-evidence-will-harm-the-people-they-claim-to-help/Research and policy
- 27.Urban Institute. Public Comment on CMS's Interim Final Rule on Medicaid Community Engagement Requirements. August 2026. https://www.urban.org/research/publication/public-comment-cmss-interim-final-rule-medicaid-community-engagementResearch and policy
- 28.KFF. Different Data Source, But Same Results: Most Adults Subject to Medicaid Work Requirements Are Working or Face Barriers to Work. 2025. https://www.kff.org/medicaid/different-data-source-but-same-results-most-adults-subject-to-medicaid-work-requirements-are-working-or-face-barriers-to-work/Research and policy
- 29.NBC News. Nebraska rolls out Medicaid work requirements, putting thousands at risk of losing coverage. May 1, 2026. https://www.nbcnews.com/health/health-news/nebraska-rolls-medicaid-work-requirements-putting-thousands-risk-losin-rcna342900News and industry
- 30.Becker's Hospital Review. Arkansas Medicaid work requirement lowered number of insured, didn't boost employment, study finds. 2019. https://www.beckershospitalreview.com/payer-issues/arkansas-medicaid-work-requirement-lowered-number-of-insured-didn-t-boost-employment-study-finds.htmlNews and industry
- 31.Harvard T.H. Chan School of Public Health. Coverage losses, substantial confusion in Arkansas following implementation of Medicaid work requirements (Sommers BD, et al., New England Journal of Medicine, 2019). https://hsph.harvard.edu/news/coverage-losses-substantial-confusion-in-arkansas-following-implementation-of-medicaid-work-requirements/Research and policy
- 32.Emory University Rollins School of Public Health. What Three Years of Georgia's Medicaid Work Requirement Show as the Policy Goes National. July 2026. https://sph.emory.edu/news/what-three-years-georgias-medicaid-work-requirement-show-policy-goes-nationalResearch and policy
- 33.Federal watchdog report on Georgia's Medicaid program raises concerns about administrative costs. Bangor Daily News (wire report); September 2025. https://www.bangordailynews.com/2025/09/18/nation/federal-watchdog-report-on-georgias-medicaid-program-raises-concerns-about-administrative-costs/News and industry
- 34.Georgia Budget and Policy Institute. Pathways to Coverage: Where Georgia's Experiment with a Medicaid Work Requirement Stands after Three Years of Enrollment. October 2026. https://gbpi.org/pathways-to-coverage-three-years/Research and policy
- 35.Healthcare Dive. Nebraska rolls out Medicaid work requirements, putting tens of thousands at risk of coverage losses. May 1, 2026. https://www.healthcaredive.com/news/nebraska-medicaid-work-requirements-launch-first-state/818992/News and industry
- 36.Medicaid Work Check. Montana's Medicaid Work Requirement: What Happens October 1 (citing a Montana Healthcare Foundation estimate reported by Wisconsin Watch). September 2026. https://medicaidworkcheck.com/blog/montana-medicaid-work-requirement-october-1-disenrollmentNews and industry
- 37.KFF Health News. Montana Hurries To Adopt Trump's Medicaid Work Rules Amid Budget Woes. May 2026. https://kffhealthnews.org/medicaid/medicaid-work-requirements-trump-montana-budget-shortfalls/News and industry
- 38.Arkansas Advocate. Arkansas has begun a 'soft launch' of Medicaid work requirements. What does that mean? July 2026. https://arkansasadvocate.com/?p=27065News and industry
- 39.Civil Rights Litigation Clearinghouse. Commonwealth of Massachusetts v. Oz, 1:26-cv-12962 (D. Mass.). 2026. https://clearinghouse.net/case/48333/Official and legal
- 40.American Medical Association. CMS releases medical frailty work-requirement guidance for Medicaid. October 2026. https://www.ama-assn.org/health-care-advocacy/access-care/cms-releases-medical-frailty-work-requirement-guidance-medicaidResearch and policy
- 41.National Health Law Program. NHeLP Files Amicus in Massachusetts v. Oz. September 2026. https://healthlaw.org/news/nhelp-files-amicus-in-massachusetts-v-oz/Research and policy
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- 43.Freedinsure. Medicaid Work Requirements: What Changes January 1, 2027 (status of state delay requests as of October 7, 2026). https://www.freedinsure.com/health-insurance-news/medicaid-work-requirements/News and industry
- 44.Georgetown University Center for Children and Families. Are States Ready to Implement HR 1 and Medicaid Work Reporting Requirements? September 2025. https://ccf.georgetown.edu/2025/09/04/are-states-ready-to-implement-hr-1-and-medicaid-work-reporting-requirements/Research and policy
- 45.Missouri Independent. Missouri rejects optional hardship exceptions to Medicaid work requirements. 2026. https://missouriindependent.com/?p=33088News and industry
- 46.Nebraska Hospital Association. Nebraska Hospitals Warn Medicaid Work Rules Could Disrupt Care. April 14, 2026. https://www.nebraskahospitals.org/nebraska-hospitals-warn-medicaid-work-rules-could-disrupt-careNews and industry
- 47.Take Command. ACA 2026 in review: What enrollment data, 2027 rate filings, and the courts have settled. August 2026. https://www.takecommandhealth.com/blog/aca-2026-updates-in-reviewNews and industry
- 48.Missouri Department of Social Services. H.R.1 Implementation. 2026. https://dss.mo.gov/hr1-implementationOfficial and legal
- 49.Gooch K. 43% of hospitals are in the red: 6 financial notes. Becker's Hospital Review; October 2026. https://www.beckershospitalreview.com/finance/43-of-hospitals-are-in-the-red-6-financial-notes/News and industry
- 50.Bruce G. Why 43% of hospitals are losing money. Becker's Hospital Review; October 8, 2026. https://beckershospitalreview.com/finance/why-43-of-hospitals-are-losing-moneyNews and industry
- 51.WVIA. PSU rural health expert says coming Medicaid changes could mean more struggles for hospitals. August 1, 2026. https://www.wvia.org/news/local/2026-08-01/psu-rural-health-expert-says-coming-medicaid-changes-could-mean-more-struggles-for-hospitalsNews and industry
- 52.Paragon Health Institute. Statement on CMS Interim Final Rule Regarding Medicaid Work Requirements. June 2026. https://paragoninstitute.org/news/statement-from-the-paragon-health-institute-on-cms-interim-final-rule-regarding-medicaid-work-requirements/Research and policy
- 53.KATV. Arkansas DHS prepares revised Medicaid work and engagement rules for beneficiaries. 2026. https://katv.com/news/local/arkansas-dhs-prepares-revised-medicaid-work-and-engagement-rules-for-beneficiaries-katv-news-share-inform-community-assist-public-health-safetyNews and industry
- 54.KFF. Poll: Most Support Adding Work Requirements to Medicaid, but Views Shift with Arguments Made for and Against. 2025. https://www.kff.org/f05c7aaResearch and policy
- 55.Montana Free Press. Most Montanans support work requirements for Medicaid beneficiaries. March 4, 2026. https://montanafreepress.org/2026/03/04/most-montanans-support-work-requirements-for-medicaid-beneficiaries/News and industry