Health Coverage for Millions of Americans at Risk Under GOP Plan

A provision House Republicans have included in their sweeping tax and spending bill threatens the health coverage of millions of Americans, according to independent analyses.

GOP members are proposing certain Medicaid beneficiaries between the ages of 19 and 64 meet employment requirements, which involve completing 80 hours of work, community service, a work program or an educational program. These requirements would start at the beginning of 2029.

Republicans released the portion of bill text outlining the Medicaid changes on Sunday night as part of their larger reconciliation bill that allows them to pass budget measures without the support of Democrats. The House Energy and Commerce Committee plans to mark up the legislation Tuesday. The panel was tasked with finding $880 billion in savings to help fund President Donald Trump’s campaign-promised tax cuts.

Work requirements are not a new idea for the Medicaid program, but this would be the first time they would be mandated nationwide if Congress clears the legislation.

States like Arkansas, New Hampshire and Georgia have implemented similar requirements, resulting in thousands of beneficiaries losing or struggling to attain coverage. President Donald Trump’s first administration allowed states to impose their own rules around work and community engagement for Medicaid beneficiaries.

Approximately 4.6 to 5.2 million individuals aged 19 to 55 in the Medicaid expansion population would lose coverage in 2026 if similar work requirements are implemented nationwide, according to a Robert Wood Johnson Foundation and the Urban Institute estimate. A vast majority of the adults in this population already work or would be exempted, but are still likely to lose coverage, the April report said, due to low awareness and understanding of the requirements.

New Hampshire moved forward with work requirements for beneficiaries aged 19 through 64 in June 2019. But by July, the state suspended the requirements or else risked finding around 17,000 beneficiaries out of compliance, according to an analysis by the Urban Institute think tank. Arkansas started phasing in work requirements in June 2018 for beneficiaries 30 to 49 years’ old, and then added 19 to 29-year-old individuals starting in 2019. By the time the work requirements were halted by a court in March 2019, approximately 18,000 people had lost coverage, according to a letter from federal officials to the state in 2021.

Protestors hold signs at a protect Medicaid rally on May 7, 2025 in Washington. About 4.6 to 5.2 million individuals aged 19 to 55 in the Medicaid expansion population would lose coverage in 2026 if work requirements are implemented nationwide, according to independent analysis.

Photographer: Leigh Vogel/Getty Images for Caring Across Generations

Rep. Frank Pallone (D-N.J.), ranking member of the House Energy and Commerce Committee, released a report earlier this month warning that work requirements have led to wrongful termination of coverage for thousands of adults. The report focused in on Arkansas and Georgia, which launched work requirements in July 2023. According to the report, after 18 months, only 6,503 of the more than 240,000 Georgians that were eligible managed to enroll.

“The report finds Georgia spent way more money administering their program to kick people off Medicaid than providing health care,” Pallone said in a statement.

“This isn’t about efficiency and cost-cutting. Medicaid is the leanest health care program in the country, spending less per-person than either Medicare or private health insurance,” he said.

The bill would also place cost-sharing requirements on beneficiaries who became eligible under Medicaid expansion. Under the 2009 Affordable Care Act, states were able to expand their programs to 138% of the federal poverty level, and only 10 states have not expanded their programs. The cost-sharing is to not exceed $35 per service and 5% of the individual’s income.

House Republicans are also looking to delay Biden-era Medicaid policies by a decade and put pressure on states who may offer health coverage for undocumented immigrants.

One such regulation aimed to make it easier for individuals to obtain, and maintain, Medicaid coverage. For older beneficiaries and people who are disabled, eligibility renewals are only conducted every 12 months under the current rules. The regulation allows renewals through multiple modalities. The bill pushes implementation out to 2035.

Republicans want to remove controversial requirements that set staffing minimums in nursing homes. The regulation was repelled by long-term care trade groups and was challenged in a Texas district court, which vacated the requirements in early April.

The reconciliation bill would lay pressure on states like California that opt to provide health care coverage to undocumented immigrants. In 2024, the state allowed adults ages 26 through 49 to qualify for Medicaid regardless of immigration status. The state had already expanded Medicaid coverage to younger adults and older Americans in 2020 and 2022. Only two other states—Oregon and Minnesota—provide health coverage to all adults regardless of immigration status, according to the National Immigration Law Center.

“This policy puts undue budgetary pressure on Medicaid, thereby endangering the healthcare access of the vulnerable Americans the program was designed to help,” Guthrie said in an op-ed he wrote for the Wall Street Journal.

The bill would reduce the level of federal Medicaid funding to expansion states that provide health coverage to undocumented immigrants.