The Collateral Damage of Medicaid Work Requirements

Congressional Republicans are considering imposing work reporting requirements on Medicaid enrollees as part of the budget reconciliation process. While framed as a cost-cutting measure, Medicaid work reporting requirements only save money by creating significant coverage losses. Work reporting requirements would inflict widespread collateral damage, including hundreds of thousands of children losing Medicaid coverage, massive job losses, and tens of thousands of avoidable deaths.

Medicaid work reporting requirements will cost kids their coverage

Medicaid is the single-largest health insurer for children in the United States, covering nearly 40 percent of all children nationwide. For millions of families, Medicaid provides vital access to well-child care, youth behavioral health services, and services for special health care needs. Research shows that Medicaid coverage during childhood promotes a range of long-term benefits, including better health outcomes in adulthood, increased college enrollment, and higher adult earnings.

When parents have Medicaid coverage, their children are more likely to be insured, a dynamic known as the “welcome mat” effect. Medicaid work reporting requirements threaten to disrupt this effect by creating bureaucratic barriers that cause parents to erroneously lose their coverage. Under work requirements, parents would be forced to regularly report their employment status or participation in approved activities, such as job training or volunteering, to maintain Medicaid. The implementation of work reporting requirements in some states has demonstrated that few enrollees can keep up with the red tape, and as a result, most coverage losses result from procedural and administrative barriers, not from a lack of work. When parents lose Medicaid due to paperwork hurdles or reporting failures, their children also can lose coverage, even if they remain eligible for Medicaid.

A May 2025 Manatt analysis estimated average annual coverage losses between 2026 and 2034 by state for children under two Medicaid work reporting requirement scenarios: with requirements imposed on expansion adults ages 19 to 55 only and with requirements imposed on all nondisabled adults ages 18 to 65. The analysis assumed that for every 100 expansion adults who lose Medicaid coverage, five children lose coverage as well. Manatt’s adult coverage loss estimates were drawn from work reporting requirement implementation experiences in Georgia, New Hampshire, and Arkansas, which vary considerably. Manatt uses each state experience as a proxy for the level of automation used in administering work reporting requirements.

Table 1 presents the full range of Manatt’s predicted losses, with the highest estimates based on work reporting requirements administered in states with minimal automation (similar to Georgia) and the lowest based on implementation with greater use of automation (similar to  Arkansas). The table averages these estimates inclusive of those from a third scenario of some automation (similar to New Hampshire) to find that 480,000 children would lose coverage if Medicaid work reporting requirements applied only to expansion adults, and 914,000 children would lose coverage if work reporting requirements applied to all nondisabled adults.

If work reporting requirements were applied solely to adults eligible under the Affordable Care Act’s Medicaid expansion, states such as California, New York, Pennsylvania, Louisiana, and Illinois would experience the largest number of children losing coverage. Under the broader scenario, in which work requirements would apply to all nondisabled adults, Illinois, Ohio, and Michigan would also see tens of thousands of children lose Medicaid coverage, placing their health and well-being at risk.

Medicaid work reporting requirements will cost jobs

Medicaid is not just a source of coverage for millions of Americans: The program also plays an important role in supporting employment. As the largest source of federal funding for state budgets, Medicaid provides billions of dollars to local economies and sustains jobs in the health sector as well as other industries.

The economic consequences of Medicaid work reporting requirements would be severe. A May 2025 Commonwealth Fund analysis by Leighton Ku and colleagues estimated that nationwide implementation of work reporting requirements for expansion enrollees would result in as many as 449,000 jobs lost in 2026. The analysis found that job losses would be heavily concentrated in the health care sector, affecting hospitals, ambulatory care, and pharmaceuticals. The ripple effects of job losses would also reach industries such as retail, construction, and food production; the interconnected nature of state economies would extend these effects to Medicaid nonexpansion states as well.

Table 2 shows that Arizona, California, and New York would experience the largest job losses due to Medicaid work reporting requirements, with each state projected to lose tens of thousands of jobs in 2026 alone.

Medicaid work reporting requirements will cost lives

Coverage losses from work reporting requirements can also lead to excess deaths. The Urban Institute estimated that imposing work reporting requirements on Medicaid expansion enrollees ages 19 to 55 would cause between 4.6 million and 5.2 million people to lose coverage by 2026. According to the Urban Institute’s analysis, nearly all of those losing Medicaid coverage would become uninsured, as affordable alternatives in the marketplace or through employer-sponsored insurance would remain largely inaccessible.

A 2017 study by health economist Benjamin D. Sommers found that Medicaid expansion is linked to “one life saved annually for every 239 to 316 adults gaining insurance.” Using the conservative end of Sommers’ estimate and the midpoint of the Urban Institute’s coverage loss projection, the Center for American Progress calculates that a federal Medicaid work reporting requirement for the expansion population would result in approximately 15,400 deaths each year.

These deaths would be felt across all expansion states, though some would be hit particularly hard. In California and New York, more than 2,500 people in each state would die annually as a result of coverage losses due to Medicaid work reporting requirements. Illinois, North Carolina, Ohio, and Pennsylvania would each experience more than 500 avoidable deaths annually. 

Conclusion

The collateral damage of congressional Republican-proposed Medicaid work reporting requirements is significant: Hundreds of thousands of children could lose their coverage, up to 449,000 jobs would be lost, and 15,400 people could lose their lives each year. Medicaid work requirements are not benign administrative adjustments; they are structural barriers that disrupt access to care for entire families, destabilize the workforce, and place lives at risk.

The authors would like to thank Jill Rosenthal for her fact-checking.