Photo: Politico
A sweeping new Republican legislative package, coined the “One Big Beautiful Bill Act”, is sparking major controversy across the U.S. healthcare landscape. One of the bill’s most significant and contentious provisions is the introduction of federal work requirements for Medicaid, which could jeopardize health coverage for millions of low-income Americans.
The bill — currently moving through both the House and Senate — proposes that adults aged 19 to 64 must work at least 80 hours per month or participate in qualifying activities to maintain or gain Medicaid eligibility. Though certain exemptions apply (such as for parents or those with medical issues), policy experts say these carve-outs are often poorly implemented, leading to people falling through the cracks.
“There’s no question that millions of people will be harmed,” said Allison Orris, Senior Fellow and Director of Medicaid Policy at the Center on Budget and Policy Priorities.
According to projections by the Congressional Budget Office (CBO), if enacted, the bill could lead to a staggering 4.8 million additional uninsured Americans by 2034 due to the Medicaid work requirement alone. That figure could rise to 16 million uninsured when combined with other policy changes in the GOP budget, such as:
The CBO underscores that Medicaid cuts within the House version of the bill would slash federal spending by $344 billion over the next decade — the largest source of Medicaid savings proposed.
Under the new rules, anyone between 19 and 64 applying for Medicaid — or receiving it through the Affordable Care Act (ACA) expansion — must:
These conditions are unprecedented at the federal level. Current law does not allow Medicaid eligibility to hinge on employment, though states can request waivers to experiment with such requirements.
So far, Georgia is the only state with an active Medicaid work requirement, though several others have submitted waiver applications seeking similar authority.
Past experiments have shown troubling results. For example:
“Many people on Medicaid are already working, if they’re able,” said Robin Rudowitz, Director of Medicaid and the Uninsured at KFF, a nonpartisan health policy organization.
The Senate version of the bill introduces even tougher provisions than the House’s proposal, including:
Critics argue the bill risks disproportionately harming vulnerable populations, including low-wage workers, part-time employees, people with chronic illnesses, and those facing language barriers or administrative hurdles.
They note that:
The “One Big Beautiful Bill Act” is far more than political branding — it’s a policy pivot with sweeping implications for the U.S. healthcare system. While Republicans argue it promotes accountability and workforce participation, analysts warn of widespread disenrollment, legal challenges, and increased uninsured rates.
As the bill advances through Congress, millions of Americans — especially those in the Medicaid expansion group — are watching closely to see if access to their healthcare hangs in the balance.