Work requirements for some Medicaid recipients begin in the United States in January, a result of President Donald Trump’s big tax cut and 2025 policy bill, and a handful of Republican-led states are imposing stricter rules than the law requires.
The question is how can anyone prove that he is too medically fragile to work. While federal regulations say the state can take the recipient’s word for the first year, at least six states require documentation immediately. There is constant pressure in other states to eventually follow suit.
Advocates say that could create problems, particularly for new applicants to the joint state-federal health insurance program for low-income people.
“Someone may not be able to work, but they can’t see a doctor because they can’t afford it. So they’re now applying for Medicaid,” said Jennifer Tolbert, director of state health policy and data at the research organization KFF. “But Medicaid says you need documentation from a provider.”
While some Republican-led states are taking a tougher-than-necessary approach to implementing federally mandated changes, Democrats in 25 states continue and saying the rules are too harsh.
Some say documentary evidence is necessary to avoid fraud
Changes to Medicaid are expected to save the federal government $887 billion over the next decade and reduce the number of people with health insurance by 7.5 million, according to the Congressional Budget Office’s 2025 estimate.
The conservative Foundation for Government Accountability urged states not to make it too easy for people to avoid work requirements, saying able-bodied adults are pushing enrollment and costs higher.
Jonathan Ingram, the group’s vice president of research and policy, encouraged states not to take a beneficiary’s word for it, a process known as self-attestation.
“Self-attestation is intentional fraud,” he said via email. “This is a policy developed by bureaucrats to maximize enrollment at the expense of program integrity. »
Self-attestation is punishable by perjury, so people who lie may face criminal prosecution – although such charges are rare.
Arkansas, Idaho, Indiana, New Hampshire, North Carolina, and Ohio all have laws or policies that prohibit self-certification to qualify for the work requirements exception starting next year.
Missouri Republican state Rep. Darin Chappell said he worked with the Foundation for Government Accountability to develop a proposed amendment that would have enshrined Medicaid work requirements in the state constitution. It would have required “documentary evidence” of work or grounds for exemption, specifically prohibiting self-attestation.
The amendment passed the Missouri House but died without a vote in the Senate. Chappell plans to try again next year.
“If someone has a debilitating physical illness – or a mental illness for that matter – something that prohibits them from working, that’s completely legitimate,” he said. “But we don’t take anyone’s word for it. I don’t want to shock you, but people tend to lie about this sort of thing.”
Most non-disabled beneficiaries under 65 are already working
The new mandate applies to up to 20 million low-income adults without children at home who are enrolled in Medicaid through an optional expansion in 40 states and the District of Columbia. This requirement does not apply in the 10 states, mostly in the South, that have not expanded Medicaid.
Recipients will need to work or volunteer at least 80 hours per month or be in school at least half-time to qualify, with exceptions for situations such as medical frailty.
The law specifies that medically fragile people include those with substance use disorders, disabilities, or serious health conditions. But the Centers for Medicare and Medicaid Services published a rule in June, it went further and was stricter than states and providers expected, saying a person’s condition must “significantly impair” their ability to work, volunteer or attend school, as an exemption requires.
Currently, states typically decide once a year whether Medicaid recipients are still eligible for benefits. The new law will require this to happen twice for most enrollees.
States will be allowed to accept self-attestation only once each time a person enrolls starting in 2028. After that, documentation will be required at least every 12 months to verify that they still have the disease and that it still prevents them from being able to work.
The government expects states to increasingly rely on third-party data — on things like workers’ compensation claims or prescription information — to help them make decisions. For conditions that do not appear in databases, states may require a medical certificate, disability compensation letter, or other proof.
Although states have ramped up use of this information, the work requirements are still a significant change, and many will first need to spend millions of dollars improve their IT systems.
States are already struggling in some cases to make changes to the Supplemental Nutrition Assistance Program, or SNAP, that are required by the Trump law, including an expanded work requirement.
In Arizona, for example, enrollment fell 55% between April 2025 and April 2026 – the largest decline in the country – with more than 400,000 fewer people now receiving benefits. Last month, the state said this was largely due to difficulties in implementing new federal requirements, leading to increased call volumes and additional audits.
Patient advocates fear help will be denied to qualified people
Ingram said some of the concerns about ending self-certification are overblown and that people can get diagnoses to support their inability to work in many places, including charitable clinics and federally qualified health centers. He also noted that Medicaid allows retroactive coverage for doctor visits that occur before enrollment.
Patient advocates say it’s not that simple.
“The extra paperwork, the hoops you have to jump through results in a loss of coverage,” said Nate Crippes, an attorney at the Disability Law Center in Utah, where a law allows self-attestation to qualify for the work requirements exception on an interim basis.
An additional challenge is that most people in his state’s Medicaid expansion group have a mental health or substance use disorder diagnosis — or both.
“We choose to put people with health conditions through a lot of barriers,” said Camille Richoux, health policy director at Arkansas Advocates for Children and Families.
This can be tricky if states decide to rely in part on patients’ diagnosis codes to determine whether beneficiaries are able to work.
Lucy Dagneau, senior director of the American Cancer Society Cancer Action Network’s national and local campaigns team, said the codes do not indicate the severity of a disease. For example, some patients with a specific cancer can continue to work, she explained, but others at a more advanced stage cannot.
“Our fear is that by banning self-attestation, unfortunately, state legislators who pass these laws will contribute to more people losing coverage in their state than they would have,” she said.
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Associated Press writers David A. Lieb in Jefferson City, Missouri, and Laura Turbay in Little Rock, Arkansas, contributed.
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