Samantha Liss, Author at �鶹Ů�� Health News

New Federal Medicaid Rules Require One Month of Work. Some States Demand More.

Samantha Liss — Thu, 16 Apr 2026 09:00:00 +0000

Millions of people who apply for Medicaid in the coming years will have to prove they’ve been working, going to school, or volunteering for at least a month before they can gain or retain health insurance through the government program.

But Republican lawmakers in some states think the new rules — part of the GOP’s One Big Beautiful Bill Act, signed last July by President Donald Trump — don’t go far enough.

Indiana is leading that charge, with a new law that requires applicants to prove they’ve been working or participating in a similar activity for three consecutive months to get benefits.

Meanwhile, residents in many other states will have to show they’ve been working just one month, the least cumbersome option under Trump’s signature tax-and-domestic-spending law. It instructs states to decide whether to require one, two, or three months of work history.

As in Indiana, Republican Idaho lawmakers approved a three-month requirement, and the state’s governor signed the bill into law on April 10.

The efforts, along with similar moves in Arizona, Missouri, and Kentucky, are aimed at restricting flexibility to implement the federal law at the state level.

“Normally, you would not see state legislators weighing in on these decisions,” said Lucy Dagneau, a senior official with the American Cancer Society’s advocacy arm.

The nonpartisan Congressional Budget Office estimated 18.5 million adults will be subject to the new rules, which will be enforced across 42 states and the District of Columbia. In Indiana, work rules will target about 33% of the state’s Medicaid population. The rules generally wouldn’t apply to children, people 65 or older, or people with disabilities or serious health issues.

Typically, state administrators — not lawmakers — detail how they plan to comply with new federal standards, and they often look to federal regulators for guidance. But officials at the Centers for Medicare & Medicaid Services have yet to tell states how to comply with many aspects of the sweeping budget law, leaving state lawmakers to intervene.

Gov. Mike Braun, a Republican, signed the Indiana bill into law on March 4, making his state the first to set the Medicaid work requirement at three months — the longest period allowed under the federal law.

Republican state Sen. Chris Garten introduced a bill in January, saying it was needed to “align” state law with the new federal Medicaid rules. He also pitched the bill as a way to crack down on “waste, fraud, and abuse” in public programs.

When ineligible people get enrolled, it robs “the truly vulnerable Hoosier who actually needs the help,” Garten said during a January committee hearing.

Democratic state Sen. Fady Qaddoura expressed skepticism during the hearing and questioned the necessity of the legislation. Qaddoura asked Indiana Family and Social Services Administration Secretary Mitch Roob to provide an estimate of the number of ineligible people who enrolled in Medicaid in the state.

“I think very few,” Roob replied. “It’ll never be none.”

After hearing Roob’s answer, Qaddoura said there is no evidence of a widespread problem in Indiana. He accused Republicans of using waste, fraud, and abuse as justification to deny health benefits and food aid to vulnerable Hoosiers.

Garten later called Qaddoura’s accusation a “fundamental mischaracterization” of the bill.

Republicans have said imposing these limits protects the Medicaid program’s longevity.

“We believe in a safety net for our most vulnerable, not a hammock for able-bodied adults that choose not to work,” Garten said. “By tightening these screws, we ensure that our safety net remains sustainable.”

Indiana’s Medicaid enrollment is expected to decrease because of Garten’s legislation, according to an analysis from Indiana’s nonpartisan Legislative Services Agency.

Medicaid helps keep people healthy, so they can continue to work, said Adam Mueller, executive director of the Indiana Justice Project, a nonpartisan legal advocacy organization focusing on health, housing, and food insecurity.

Mueller worries that people will struggle to prove their work history, especially those with nontraditional jobs.

“If the point is to get people engaged, the one month would do it,” Mueller said.

Ultimately, he fears the law will harm Hoosiers with the greatest need for assistance. “They’re going to get tripped up by the bureaucratic hurdles.”

An analysis by the Center on Budget and Policy Priorities predicted that work rules will and that how states choose to implement the rules will “significantly affect the number of people who lose coverage.” State policy decisions will determine just “how intense the burden is,” the left-leaning think tank found, and opting for a shorter look-back period “will enable more people to enroll.”

Lawmakers in multiple states considered limits. And the same right-leaning lobbying group, the Foundation for Government Accountability, testified in favor of these measures in Arizona, Indiana, and Missouri.

In Missouri, FGA lobbyist James Harris said the measure intends to “move people from dependency and give them back that dignity and pride of work.”

Missouri state Rep. Darin Chappell proposed requiring a three-month look-back period like the measure in Indiana. But the latest version of the bill he sponsored would require applicants to show they were working for only one month before enrolling.

Chappell, a Republican, said his initiative would encourage a “working mindset.”

Anna Meyer, owner of a small bakery in Columbia, Missouri, said the implication is that she and others on Medicaid are lazy. “I have been working since I was 15 years old,” she said. “I’m 43 now.”

Meyer, who voiced her opposition, said she previously had problems submitting information to the state Medicaid agency. She fears new reporting requirements will put her and others at risk of losing coverage, even if they meet the work rule.

She has fibromyalgia, a chronic condition that increases overall sensitivity to pain. She also has food allergies. Medicaid helps pay for medications and doctor visits that keep her healthy and allow her to keep working.

“I work very hard,” Meyer said.

In St. Louis, Jessica Norton, an OB-GYN, treats many Medicaid patients at an Affinia Healthcare clinic. She said they struggle to remain insured even though Missouri extends a full year of Medicaid coverage to eligible women after they give birth. Some of her patients are inexplicably kicked off that coverage by the time of their checkups six weeks after birth. She fears red tape from the new work requirements will make it harder to hang on to insurance, even though pregnant women and new mothers are supposed to be exempt.

Norton criticized lawmakers for the message this policy sends to vulnerable patients. They are saying, “Oh, actually, health care is a privilege, and you have to earn it,” she said.

Norton speaks with patient Candis Quinn on April 7. Norton fears women will bear the brunt of new Medicaid work requirements because they’re often performing unpaid labor. (Samantha Liss/�鶹Ů�� Health News)

of adults ages 19 to 64 on Medicaid already work, according to �鶹Ů��. The reason many of the remaining adults on Medicaid are not working is that they are retired, serving as a caregiver, or too sick, �鶹Ů�� has found.

Some states are not only setting the strictest requirements but also blocking out the optional leniency built into the federal rules.

For example, states may adopt additional exemptions from work rules, such as allowing people to claim a “short-term hardship,” designed to provide continued Medicaid coverage to people with medical conditions that prevent them from working.

Missouri lawmakers are seeking a constitutional amendment to bar their state from offering such optional exemptions. But patient advocates warn these limits would harm the state’s vulnerable residents when they need coverage the most, particularly Missouri’s rural cancer patients.

Often, rural Missouri patients must travel to Kansas City or St. Louis for treatment, disrupting their ability to work, Emily Kalmer, a lobbyist for the American Cancer Society’s advocacy arm, testified at the January hearing. Recognizing this, the federal law provides certain exemptions for this kind of scenario.

But this short-term hardship exemption would be off the table in Missouri.

Time is “very important in the life of a cancer patient or a cancer survivor,” Kalmer said.

�鶹Ů�� Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at �鶹Ů��—an independent source of health policy research, polling, and journalism. Learn more about .

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How Medicaid Contractors Stand To Gain From Trump’s Policy

Samantha Liss — Fri, 03 Apr 2026 18:30:00 +0000

States are paying contractors such as Deloitte, Accenture, and Optum millions of dollars to help them comply with the One Big Beautiful Bill Act — a law that will strip safety-net health and food benefits from millions.

State governments rely on such companies to design and operate computer systems that assess whether low-income people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly known as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a �鶹Ů�� Health News investigation showed.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax-and-spending law. The changes will add red tape and restrictions. They are coming at a steep price ― both in the cost to taxpayers and coverage losses ― according to state documents obtained by �鶹Ů�� Health News and interviews.

The documents show��government agencies��will spend millions��to save��considerably��more��by��removing��people from��health benefits.��While states��sign��eligibility system contracts with companies��and��work with them to manage��updates, the federal government��foots��most of the bill.

The law’s Medicaid policies will cause��to��become uninsured��by 2034, according to the nonpartisan Congressional Budget Office.��Roughly��will lose��access to��monthly cash��assistance��for��food, including those with children.��

In five states��alone,��for state officials��and reviewed by �鶹Ů�� Health News��show that changes��will cost at least $45.6��million��combined.��

The law��requires most states��to��tie��Medicaid coverage��for some adults��to��having��a��job,��and��imposes other restrictions that will make it harder for��people��with low incomes��to stay enrolled.��SNAP restrictions began to take effect in 2025. Major Medicaid provisions��begin��later this year.��

Documents��prepared by consulting company Deloitte��estimate��that a pair of��computer system��changes��for��Medicaid work requirements��in Wisconsin��will��. Two other changes��related��to the state’s SNAP program will cost an additional $4.2��million, according to the documents, which for the Wisconsin Department of Health Services.

In Iowa, changes to its Medicaid system are expected to cost at least $20 million, , a consulting company that��operates��the state’s��eligibility system.��

Optum��—��which��operates��the platform Vermont residents use��for Medicaid and marketplace��health��plans under the Affordable Care Act��—��to��evaluate and��incorporate��new��health��coverage restrictions.��

Initial changes in Kentucky, which has had a contract with Deloitte since 2012,��. And in Illinois,��will cost at least $12 million.

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States Pay Deloitte, Others Millions To Comply With Trump Law To Cut Medicaid Rolls

Samantha Liss — Tue, 31 Mar 2026 09:00:00 +0000

State governments rely on such companies to design and operate computer systems that assess whether low-income people qualify for Medicaid or food aid through the Supplemental Nutrition Assistance Program, commonly referred to as food stamps. Those state systems have a history of errors that can cut off benefits to eligible people, a �鶹Ů�� Health News investigation showed.

These benefits, provided to the poorest Americans, can mean the difference between someone obtaining medical care and having enough to eat — or going without.

States are now racing to update their eligibility systems to adhere to President Donald Trump’s sweeping tax and domestic spending law. The changes will add red tape and restrictions. They are coming at a steep price — both in the cost to taxpayers and coverage losses — according to state documents obtained by �鶹Ů�� Health News and interviews.

The documents show government agencies will spend millions to save considerably more by removing people from health benefits. While states sign eligibility system contracts with companies and work with them to manage updates, the federal government foots most of the bill.

The law’s Medicaid policies will cause to become uninsured by 2034, according to the nonpartisan Congressional Budget Office. Roughly will lose access to monthly cash assistance for food, including those with children.

In five states alone, for state officials and reviewed by �鶹Ů�� Health News show that changes will cost at least $45.6 million combined.

“This is a pretty big payday,” said Adrianna McIntyre, an assistant professor of health policy and politics at Harvard’s T.H. Chan School of Public Health.

The law, which grants tax breaks to the nation’s wealthiest people, requires most states to tie Medicaid coverage for some adults to having a job, and imposes other restrictions that will make it harder for people with low incomes to stay enrolled. SNAP restrictions began to take effect in 2025. Major Medicaid provisions begin later this year.

Documents prepared by consulting company Deloitte estimate that a pair of computer system changes for Medicaid work requirements in Wisconsin will . Two other changes related to the state’s SNAP program will cost an additional $4.2 million, according to the documents, which for the Wisconsin Department of Health Services.

In Iowa, changes to its Medicaid system are expected to cost at least $20 million, , a consulting company that operates the state’s eligibility system.

Optum — which operates the platform Vermont residents use for Medicaid and marketplace health plans under the Affordable Care Act — to evaluate and incorporate new health coverage restrictions.

Initial changes in Kentucky, which has had a contract with Deloitte since 2012, . And in Illinois, will cost at least $12 million.

A Historic Mandate

For six decades after President Lyndon Johnson created the government insurance program in 1965, Congress had never mandated that Medicaid enrollees have a job, volunteer, or go to school.

That will change next year. The tax and spending law enacted by Trump and congressional Republicans requires millions of Medicaid enrollees in 42 states and the District of Columbia to prove they’re working or participating in a similar activity for 80 hours a month, unless they qualify for an exemption. The CBO projected, based on an early version of the bill, that 18.5 million adults would be subject to the new rules — .

Vermont Medicaid officials expect it will cost $5 million in fiscal 2027 to implement changes in response to the federal law, said Adaline Strumolo, deputy commissioner of the Department of Vermont Health Access. About $1.8 million is for Optum to make eligibility system adjustments. Optum is a subsidiary of UnitedHealth Group.

The One Big Beautiful Bill Act will subject nearly 55,000 Vermont Medicaid recipients to work requirements — about a third of the state’s enrollees.

The law forced the state “to essentially drop everything else we were doing,” Strumolo said in an interview. “This is a big, big lift.”

Optum’s contract with the state was as of October.

of adult Medicaid enrollees nationally are already working, according to �鶹Ů��. Advocacy groups for Medicaid recipients say work requirements will nonetheless cause significant coverage losses. Enrollees will face added red tape to prove they’re complying. And eligibility systems already prone to error will have to account for employment, job-related activities, and any exemptions.

An estimated 5.3 million enrollees will become uninsured by 2034 due to work requirements, the .

In Wisconsin, state officials estimate could lose coverage after work requirements take effect. Not covering those people would in Medicaid spending for one year.

Wisconsin’s eligibility system for Medicaid and SNAP — known as CARES — in 1994, and initially was a transfer system from Florida, according to a 2016 state document.

Deloitte submitted its cost estimates for Medicaid and SNAP changes to the state in September and December. Elizabeth Goodsitt, a spokesperson for the Wisconsin Department of Health Services, declined to answer questions about whether additional changes will be needed, how much it will cost to make all eligibility system changes to comply with the new federal law, and whether the state negotiated prices with Deloitte.

Bobby Peterson, executive director of the public interest law firm ABC for Health, said Wisconsin has invested “very little” to help people navigate the Medicaid eligibility process, which soon will become more difficult.

“But they’re very willing to throw $6 million to their contractors to create the bells and whistles,” Peterson said. “That’s where I feel a sense of frustration.”

New Hurdles for Vets and Homeless People

Medicaid work requirements are only one change required by Trump’s tax law that will make it harder to obtain safety-net benefits.

Starting in October, the law prohibits several immigrant populations from accessing Medicaid and ACA coverage, including people who have been granted asylum, refugees, and certain survivors of domestic violence or human trafficking. Beginning Dec. 31, states must verify eligibility twice a year for millions of adults — doubling state officials’ workload. And the law restricts SNAP benefits by requiring more adult recipients to work and by removing work exemptions for veterans, homeless people, and former foster youth.

Days after Trump signed the bill in July, Kentucky health officials raced to make changes to the state’s integrated eligibility system, which verifies eligibility for Medicaid, SNAP, and other programs. Deloitte operates the system under a five-year . , initial changes costing $1.6 million were labeled a “high priority” and approved on an “emergency” basis, with some of the changes to the nation’s largest food aid program going into effect almost immediately.

Officials with Kentucky’s Cabinet for Health and Family Services declined to answer a detailed list of questions, including how much it will cost to make all the modifications needed.

Deloitte spokesperson Karen Walsh said the company is working with states to implement new requirements but declined to answer questions about cost estimates in several states. “We are delivering the value and investments we committed to,” Walsh said.

In most states, government agencies rely on contractors to build and run the systems that determine eligibility for Medicaid. Many of those states also use such computer systems for SNAP. But the federal government — that is, taxpayers — to develop and implement state Medicaid eligibility systems and pays 75% of ongoing maintenance and operations expenses, according to federal regulations.

“Five, 10 years ago, I’m not sure if you would hear much mention of SNAP from a Medicaid director,” Melisa Byrd, Washington, D.C.’s Medicaid director, said in November at an annual conference of Medicaid officials. “And particularly for those with integrated eligibility systems — as D.C. is — I’m learning more about SNAP than I ever thought.”

The federal law was the topic du jour at last year’s gathering in Maryland, held at the Gaylord National Resort and Convention Center, the largest hotel between New Jersey and Florida.

Consulting companies had taken notice. Gainwell, an eligibility contractor and one of the conference’s corporate sponsors, emblazoned its logo on hotel escalators. Companies set up booths with materials promoting how they could help states and handed out snacks and swag.

“Conduent helps agencies work smarter by simplifying operations, cutting costs and driving better outcomes through intelligent automation, analytics, and innovation in fraud prevention,” read one such handout from another contractor. “Together, we can better serve residents at every step of their health journeys.” Conduent holds Medicaid eligibility and enrollment contracts in Mississippi and New Jersey, their Medicaid agencies confirmed to �鶹Ů�� Health News.

In handouts, Deloitte touted its role in “building a new era in state health care” and as “a national leader in Medicaid program and technology transformation, building a strong track record across the federal, state, and commercial health care ecosystem.” �鶹Ů�� Health News found that Deloitte, a global consultancy that generated in revenue in fiscal 2025, dominates this slice of government business.

“With Medicaid Community Engagement (CE) requirements, states are tasked with adding a new condition of Medicaid eligibility to support state and federal objectives,” added another brochure. “Deloitte offers strategic outreach and responsive support to help states engage communities, lower barriers, and address access to coverage.”

A $20.3 Million Bill in Iowa

Before Trump signed the One Big Beautiful Bill Act, Iowa lawmakers wanted to impose their own version of work requirements. They would have applied to 183,000 people before any exemptions. The new law would necessitate a change to Iowa’s Medicaid eligibility system, according to documents prepared by Accenture, which operates Iowa’s system through a .

Adding the ability to verify work status would cost up to $7 million, . By July, the cost to implement the One Big Beautiful Bill Act’s work requirements and other Medicaid provisions . Accenture’s analysis said the federal law necessitated . Making employment a condition of Medicaid benefits could cause an estimated 32,000 Iowans to lose coverage, according to a

Cutting 32,000 people from coverage in one year, a fraction of the Iowa and the federal government spend on Medicaid in a given year.

In Cedar Rapids, most of Eastern Iowa Health Center’s patients rely on Medicaid, CEO Joe Lock said. He questioned the government’s logic of spending tens of millions of dollars on a policy to remove Iowans from Medicaid.

Most of the health center’s patients live at or below the federal poverty level — currently .

“There is no benefit to this population,” Lock said.

Joe Lock is CEO of the Eastern Iowa Health Center in Cedar Rapids, Iowa. Most of the clinic’s patients rely on Medicaid. By making employment a condition of Medicaid benefits, an estimated 32,000 Iowans could lose coverage, a 2025 state document shows. “There is no benefit to this population,” Lock says. (Tony Leys/�鶹Ů�� Health News)

Danielle Sample, a spokesperson for Iowa’s Department of Health and Human Services, did not answer questions about how much it will cost to implement changes to the state’s separate SNAP eligibility system.

In Illinois, the state’s work this year is largely focused on meeting major provisions of the One Big Beautiful Bill Act. The state estimates that as many as 360,000 residents could lose Medicaid, largely due to the work requirements, said Melissa Kula, a spokesperson for the Illinois Department of Healthcare and Family Services.

Kula confirmed that — priced at $12 million — is related to Trump’s law. The estimate also mentions other work. Kula said Deloitte is charging the state a $2 million fixed fee related to work requirements.

The Trump administration has acknowledged that the work is coming at a cost. In January, top officials for the Centers for Medicare & Medicaid Services said government contractors, including Deloitte, Accenture, and Optum, have and reduced rates through 2028 to help states incorporate system changes.

“The companies were extremely excited to do this,” , the top CMS Medicaid official. “Everyone’s really focused on getting to work.”

CMS spokesperson Catherine Howden declined to answer questions about the discounts.

Goodsitt, the Wisconsin Medicaid spokesperson, declined to answer questions about whether Deloitte has discounted its rates. Officials with Kentucky’s Cabinet for Health and Family Services did not answer a detailed list of questions, including whether Deloitte extended discounts to make these changes.

It’s unclear what discounts, if any, Deloitte and Accenture have offered to individual states. Walsh, the Deloitte spokesperson, declined to answer detailed questions about the discounts the Trump administration announced this year. Accenture did not respond to repeated requests for comment.

Strumolo, the Vermont health official, said state officials discussed the announcement with Optum “in detail.”

Optum for a specific module related to Medicaid work requirements. That product is unworkable for Vermont because it would mean “moving to a new system when we don’t have to.” When asked about whether the company offered discounts, Strumolo said “not explicitly.”

In a statement, UnitedHealth Group spokesperson Tyler Mason said Optum supports state implementation of new federal requirements “with a range of options to meet their unique cost and policy needs.”

He declined to specify whether Optum discounted Vermont’s rates and how it calculated the costs of doing its work. “Optum is helping mitigate upfront implementation expenses so states can focus on approaches that reduce duplication, accelerate implementation, and manage costs over time — supporting better outcomes for individuals covered by Medicaid,” Mason said.

Strumolo said Optum’s initial changes in Vermont cover items that take effect this year and in 2027 — Medicaid work requirements, checking eligibility every six months, and prohibiting certain immigrants from qualifying for health programs.

“There’s a lot more that could come,” she said.

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New Medicaid Work Rules Likely To Hit Middle-Aged Adults Hard

Samantha Liss — Wed, 11 Feb 2026 10:00:00 +0000

Lori Kelley’s deteriorating vision has made it hard for her to find steady work.

The 59-year-old, who lives in Harrisburg, North Carolina, closed her nonprofit circus arts school last year because she could no longer see well enough to complete paperwork. She then worked making dough at a pizza shop for a bit. Currently, she sorts recyclable materials, including cans and bottles, at a local concert venue. It is her main source of income ― but the work isn’t year-round.

“This place knows me, and this place loves me,” Kelley said of her employer. “I don’t have to explain to this place why I can’t read.”

Kelley, who lives in a camper, survives on less than $10,000 a year. She says that’s possible, in part, because of her Medicaid health coverage, which pays for arthritis and anxiety medications and has enabled doctor visits to manage high blood pressure.

But she worries about losing that coverage next year, when rules take effect requiring millions of people like Kelley to work, volunteer, attend school, or perform other qualifying activities for at least 80 hours a month.

“I’m scared right now,” she said.

Lori Kelley of Harrisburg, North Carolina, has deteriorating vision that affects her livelihood. Last year, she had to shutter her nonprofit because she couldn’t see well enough to do paperwork. Under Medicaid’s new work requirements, Kelley is concerned about losing access to care for her high blood pressure and anxiety. (A.M. Stewart for �鶹Ů�� Health News)

Because her eyesight is deteriorating, Kelley uses special glasses for working on her computer at home. (A.M. Stewart for �鶹Ů�� Health News)

Before the coverage changes were signed into law, Republican lawmakers suggested that young, unemployed men were taking advantage of the government health insurance program that provides coverage to millions of low-income or disabled people. Medicaid is not intended for “29-year-old males sitting on their couches playing video games,” House .

But, in reality, adults ages 50 to 64, particularly women, are likely to be , said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at �鶹Ů��, a health information nonprofit that includes �鶹Ů�� Health News. For Kelley and others, the work requirements will create barriers to keeping their coverage, Tolbert said. Many could lose Medicaid as a result, putting their physical and financial health at risk.

Starting next January, some 20 million low-income Americans in 42 states and Washington, D.C., will need to meet the activity requirements to gain or keep Medicaid health coverage.

Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming didn’t expand their Medicaid programs to cover additional low-income adults under the Affordable Care Act, so they won’t have to implement the work rules.

The nonpartisan Congressional Budget Office predicts the work rules will result in at least 5 million fewer people with Medicaid coverage over the next decade. Work rules are the largest driver of coverage losses in the GOP budget law, which slashes nearly $1 trillion to offset the costs of tax breaks that mainly benefit the rich and increase border security, .

“We’re talking about saving money at the expense of people’s lives,” said Jane Tavares, a gerontology researcher at the University of Massachusetts Boston. “The work requirement is just a tool to do that.”

Department of Health and Human Services spokesperson Andrew Nixon said requiring “able-bodied adults” to work ensures Medicaid’s “long-term sustainability” while safeguarding it for the vulnerable. Exempt are people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship, Nixon told �鶹Ů�� Health News.

Medicaid expansion has provided a lifeline for middle-aged adults who otherwise would lack insurance, according to . Medicaid covers 1 in 5 Americans ages 50 to 64, giving them access to health coverage before they qualify for Medicare at age 65.

Among women on Medicaid, those ages 50 through 64 are more likely to face challenges keeping their coverage than their younger female peers and are likely to have a greater need for health care services, Tolbert said.

These middle-aged women are less likely to be working the required number of hours because many serve as family caregivers or have illnesses that limit their ability to work, Tolbert said.

Tavares and other researchers found that of the total Medicaid population is considered “able-bodied” and not working. This group consists largely of women who are very poor and have left the workforce to become caretakers. Among this group, 1 in 4 are 50 or older.

“They are not healthy young adults just hanging out,” the researchers stated.

Plus, making it harder for people to maintain Medicaid coverage “may actually undermine their ability to work” because their health problems go untreated, Tolbert said. Regardless, if this group loses coverage, their chronic health conditions will still need to be managed, she said.

Adults often start wrestling with health issues before they’re eligible for Medicare.

If older adults don’t have the means to pay to address health issues before age 65, they’ll ultimately be sicker when they qualify for Medicare, costing the program more money, health policy researchers said.

Many adults in their 50s or early 60s are no longer working because they’re full-time caregivers for children or older family members, said caregiver advocates, who refer to people in the group as “the sandwich generation.”

Kelley worries about Medicaid’s new work requirements, which may disrupt her treatment. (A.M. Stewart for �鶹Ů�� Health News)

Rules are set to take effect next year requiring millions of people on Medicaid to work, volunteer, attend school, or perform other qualifying activities for at least 80 hours a month. “I’m scared right now,” Kelley says. (A.M. Stewart for �鶹Ů�� Health News)

The GOP budget law does allow some caregivers to be exempted from the Medicaid work rules, but the carve-outs are “very narrow,” said Nicole Jorwic, chief program officer for the group Caring Across Generations.

She worries that people who should qualify for an exemption will fall through the cracks.

“You’re going to see family caregivers getting sicker, continuing to forgo their own care, and then you’re going to see more and more families in crisis situations,” Jorwic said.

Paula Wallace, 63, of Chidester, Arkansas, said she worked most of her adult life and now spends her days helping her husband manage his advanced cirrhosis.

After years of being uninsured, she recently gained coverage through her state’s Medicaid expansion, which means she’ll have to comply with the new work requirements to keep it. But she’s having a hard time seeing how that will be possible.

“With me being his only caregiver, I can’t go out and work away from home,” she said.

Wallace’s husband receives Social Security Disability Insurance, she said, and the law says she should be exempt from the work rules as a full-time caregiver for someone with a disability.

But federal officials have yet to issue specific guidance on how to define that exemption. And ― the only states to have run Medicaid work programs ― shows that many enrollees struggle to navigate complicated benefits systems.

“I’m very concerned,” Wallace said.

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Even as SNAP Resumes, New Work Rules Threaten Access for Years To Come

Renuka Rayasam — Wed, 03 Dec 2025 10:00:00 +0000

Alejandro Santillan-Garcia is worried he’s going to lose the aid that helps him buy food. The 20-year-old Austin resident qualified for federal food benefits last year because he aged out of the Texas foster care system, which he entered as an infant.

The Supplemental Nutrition Assistance Program — commonly referred to as food stamps, or SNAP — helps feed 42 million low-income people in the United States. Now, because of changes included in the One Big Beautiful Bill Act, to keep his food benefits Santillan-Garcia might soon have to prove to officials that he’s working.

He said he lost his last job for taking time off to go to the doctor for recurrent stomach infections. He doesn’t have a car and said he has applied to a grocery store, Walmart, Dollar General, “any place you can think of” that he could walk or ride his bike to.

“No job has hired me.”

Under the new federal budget law, to be eligible for SNAP benefits, more people are required to show that they are working, volunteering, or studying. Those who don’t file paperwork in time risk losing food aid for up to three years. States were initially instructed to start counting strikes against participants on Nov. 1, the same day that millions of people saw their SNAP benefits dry up because of the Trump administration’s refusal to fund the program during the government shutdown. But federal officials backtracked partway through the month, instead giving states until December to enforce the new rules.

The new law further limits when states and counties with high unemployment can waive recipients from requirements. But a legal battle over that provision means that the deadline for people to comply with the new rules varies depending on where recipients live, even within a state in some cases.

The U.S. Department of Agriculture did not respond to a detailed list of questions about how the new rules around SNAP will be implemented, and the White House did not respond to a request for comment about whether the rules could kick off people who rely on the program. The law did extend exemptions to many Native Americans.

Still, states must comply with new rules or accrue penalties that could force them to pay a bigger share of the program’s cost, which was about $100 billion last year.

Santillan-Garcia is worried that he will lose his federal food benefits because of new rules under Republicans’ One Big Beautiful Bill Act that make it harder for former foster care youths to qualify. (Callie Richmond for �鶹Ů�� Health News)

President Donald Trump signed the massive budget bill, along with the new SNAP rules, into law on July 4. States initially predicted they would need at least 12 months to implement such significant changes, said Chloe Green, an assistant director at the American Public Human Services Association who advises states on federal programs.

Under the law, “able-bodied” people subject to work requirements can lose access to benefits for three years if they go three months without documenting working hours.

Depending on when states implement the rules, many people could start being dropped from SNAP early next year, said Lauren Bauer, a fellow in economic studies at the Brookings Institution, a policy think tank. The changes are expected to knock at least 2.4 million people off SNAP within the next decade, according .

“It’s really hard to work if you are hungry,” Bauer said.

Many adult SNAP recipients under 55 already needed to meet work requirements before the One Big Beautiful Bill Act became law. Now, for the first time, adults ages 55 to 64 and parents whose children are all 14 or older must document 80 hours of work or other qualifying activities per month. The new law also removes exemptions for veterans, homeless people, and former foster care youths, like Santillan-Garcia, that had been in place since 2023.

Republican policymakers said the new rules are part of a broader effort to eliminate waste, fraud, and abuse in public assistance programs.

Agriculture Secretary Brooke Rollins said in November that in addition to the law, she will require millions to reapply for benefits to curb fraud, though she did not provide more details. Rollins she wants to ensure that SNAP benefits are going only to those who “are vulnerable” and “can’t survive without it.”

States are required to notify people that they are subject to changes to their SNAP benefits before they’re cut off, Green said. Some states have announced the changes on websites or by mailing recipients, but many aren’t giving enrollees much time to comply.

Anti-hunger advocates fear the changes, and confusion about them, will increase the number of people in the U.S. experiencing hunger. Food pantries have reported record numbers of people seeking help this year.

Even when adhering to the work rules, people often report challenges uploading documents and getting their benefits processed by overwhelmed state systems. In a survey of SNAP participants, about 1 in 8 adults reported having lost food benefits because they had problems filing their paperwork, according to . Some enrollees have been dropped from aid as a result of state errors and staffing shortfalls.

Pat Scott, a community health worker for the Beaverhead Resource Assistance Center in rural Dillon, Montana, is the only person within at least an hour’s drive who is helping people access public assistance, including seniors without reliable transportation. But the center is open only once a week, and Scott says she has seen people lose coverage because of problems with the state’s online portal.

Jon Ebelt, a spokesperson with the Montana health department, said the state is always working to improve its programs. He added that while some of the rules have changed, a system is already in place for reporting work requirements.

In Missoula, Montana, Jill Bonny, head of the Poverello Center, said the homeless shelter’s clients already struggle to apply for aid, because they often lose documentation amid the daily challenge of carrying everything they own. She said she’s also worried the federal changes could push more older people into homelessness if they lose SNAP benefits and are forced to pick between paying rent or buying food.

In the U.S., are the fastest-growing group experiencing homelessness, according to federal data.

Sharon Cornu is the executive director at St. Mary’s Center, which helps support homeless seniors in Oakland, California. She said the rule changes are sowing distrust. “This is not normal. We are not playing by the regular rules,” Cornu said, referring to the federal changes. “This is punitive and mean-spirited.”

In early November, a federal judge in Rhode Island ordered the Trump administration to deliver full SNAP payments during the government shutdown, which ended Nov. 12. That same judge sought to buffer some of the incoming work requirements. He ordered the government to respect existing agreements that waive work requirements in some states and counties until each agreement is set to end. In total, and the District of Columbia had such exemptions, with different end dates.

Adding to the confusion, some states, including New Mexico, have waivers that mean people in different counties will be subject to the rules at different times.

If states don’t accurately document SNAP enrollees’ work status, they will be forced to pay later on, Green said. Under the new law, states must cover a portion of the food costs for the first time — and the amount depends on how accurately they calculate benefits.

During the government shutdown, when no one received SNAP benefits, Santillan-Garcia and his girlfriend relied on grocery gift cards they received from a nonprofit to prioritize feeding his girlfriend’s baby. They went to a food pantry for themselves, even though many foods, including dairy, make Santillan-Garcia sick.

He’s worried that he’ll be in that position again in February when he must renew his benefits — without the exemption for former foster care youths. Texas officials have yet to inform him about what he will need to do to stay on SNAP.

Santillan-Garcia said he’s praying that, if he is unable to find a job, he can figure out another way to ensure he qualifies for SNAP long-term.

“They’ll probably take it away from me,” he said.

Because of new rules included in the One Big Beautiful Bill Act, to keep his food benefits, Santillan-Garcia might soon have to prove to officials that he’s working. (Callie Richmond for �鶹Ů�� Health News)

What You Should Know

Changes to SNAP removed work-requirement exemptions for:

People ages 55 to 64.
Caretakers of dependent children 14 or older
Veterans
People without housing
People 24 or younger who aged out of foster care

What SNAP Participants Should Do:

Check with public assistance organizations to find out when the new rules go into effect in your region. Your benefits may be checked at recertification, but you may be required to meet the monthly work reporting rules long before that.
Let your state know if you’re responsible for a dependent child younger than 14 who lives in your home; pregnant; a student at least half the time; attending a drug or alcohol treatment program; physically or mentally unable to work; a Native American; or a caretaker of an incapacitated household member. If so, you may still be exempt.

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Medicaid Work Rules Exempt the ‘Medically Frail.’ Deciding Who Qualifies Is Tricky.

Samantha Liss — Mon, 01 Dec 2025 10:00:00 +0000

Eliza Brader worries she soon will need to prove she’s working to continue receiving Medicaid health coverage. She doesn’t think she should have to.

The 27-year-old resident of Bloomington, Indiana, has a pacemaker and a painful joint disease. She also has fused vertebrae in her neck from a spinal injury, preventing her from turning her head.

Indiana’s Medicaid agency currently considers Brader “medically frail,” giving her access to an expanded set of benefits, such as physical therapy.

New federal rules will require more than 18 million Medicaid enrollees nationwide to show they’re working, volunteering, or going to school for 80 hours a month starting in 2027 to keep their coverage. Brader is exempt as long as she’s deemed medically frail.

But lacking sufficient federal guidance, states are wrestling with how to define medical frailty — a consequential decision that could cut Medicaid coverage for many people, said state officials, consumer advocates, and health policy researchers.

“It’s terrifying,” Brader said. “I already have fought so hard to get my health care.”

‘Incredibly High’ Stakes

President Donald Trump’s One Big Beautiful Bill Act slashes nearly $1 trillion from Medicaid over the next decade, with much of the savings projected to come from no longer covering those who don’t qualify under the new work rules. Those spending cuts help offset the costs of GOP priorities, such as extra border security and tax cuts that mainly benefit the wealthy.

Conservative lawmakers have argued that Medicaid, the government health insurance program for people with low incomes or with disabilities, has grown too large and expensive, especially in the wake of its expansion to more low-income adults under the Affordable Care Act. They also say that requiring participants to work is common sense.

The work rules in Trump’s tax-and-spending law offer exemptions for several groups who might struggle to meet them, including people deemed “medically frail.” The law spells out certain “medically frail” conditions such as blindness, disability, and substance use disorder. But it does not list many others.

Instead, the law exempts those with a “serious or complex medical condition,” a term whose interpretation could vary by state.

State officials say they need more clarity to ensure that people who cannot work for health reasons retain rightful access to Medicaid. They also worry that, even with a clear definition, people will face the onerous task of having to regularly vouch for being medically frail, which is a challenge without reliable access to medical care.

“The stakes are incredibly high,” said Kinda Serafi, a partner at consulting firm Manatt Health.

The new work requirements will affect Medicaid recipients in 42 states and Washington, D.C. Eight states — Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming — did not expand their Medicaid programs to cover additional low-income adults, so they won’t have to implement the work rules.

The Medicaid work rules are expected to be the over the next decade, according to the nonpartisan Congressional Budget Office.

Forty-four percent of all adults covered by states’ expanded Medicaid programs , according to �鶹Ů��.

A Challenge for States

State Medicaid agencies are scrambling to implement the rules with little direction from the U.S. Department of Health and Human Services, which has yet to issue specific guidance. Federal officials will clarify the “medically frail” definition next year, said Andrew Nixon, an agency spokesperson.

Ultimately, states will have to decide who is unhealthy enough to be exempt from work rules. And it won’t be easy for state workers and their computer systems to track.

Every year, state eligibility systems screen millions of applicants to check if they qualify for Medicaid and other government programs. Now, these same systems must screen applicants and existing enrollees to determine whether they meet the new work rules.

Jessica Kahn, a partner at consulting firm McKinsey & Co., has urged states to start planning how to adapt eligibility systems to verify work status. States can do a “tremendous amount” of work without direction from the federal government, said Kahn, a former federal Medicaid systems official, who spoke during a recent Medicaid advisory panel hearing. “Time is a-wasting already.”

State Medicaid directors are pondering the challenge.

“Medical frailty gets so complex,” Emma Sandoe, Oregon’s Medicaid director, said during a recent panel discussion. Conditions that can keep people from working, such as mental health disorders, can be hard to prove, she said.

A state might try to use data pulled from a person’s health records, for instance, to determine medical frailty. But information from a patient’s chart may not paint a clear picture of someone’s health, especially if they lack regular access to medical care.

It’s a tall order for eligibility systems that historically have not had to scrape medical records to screen applicants, said Serafi of Manatt Health.

“That is an incredibly new thing that eligibility enrollment systems are just not fluent in at all,” Serafi said.

Lobbying groups for the private health insurance companies that help run Medicaid in many states also have urged federal regulators to clearly define medical frailty so it can be applied uniformly.

In a to federal officials, the Medicaid Health Plans of America and the Association for Community Affiliated Plans advocated for allowing enrollees to qualify for the exemption by saying on their applications that they have conditions that make them medically frail. Successfully implementing exemptions for the medically frail will be “crucial” given the “severe health risks of coverage loss for these populations,” the groups said.

Some state officials worry about unintended consequences of the work rules for people with chronic conditions.

Brader worries the additional red tape will cause her to lose her Medicaid coverage. “It’s terrifying,” she says. “I already have fought so hard to get my health care.” (Chris Bergin for �鶹Ů�� Health News)

Jennifer Strohecker, who recently resigned as Utah’s Medicaid director, reiterated the high stakes, especially for those with diabetes on Medicaid. They may be very healthy and functional with insulin, but if they fail to complete the work requirements, that may change, Strohecker said during a recent Medicaid advisory hearing.

Whether someone is deemed medically frail already depends heavily on where they live.

For example, in Arkansas, people indicate on their Medicaid applications that they’re disabled, blind, or need help with daily living activities.

Approximately 6% of the roughly 221,000 people enrolled in Arkansas’ Medicaid expansion program are deemed medically frail, according to Gavin Lesnick, a spokesperson for the Arkansas Department of Human Services.

In West Virginia, the state accepts a medical frailty designation when an applicant self-reports it.

The burden of proof is higher in North Dakota. Applicants there must answer a questionnaire about their health and submit additional documentation, which may include medical chart notes and treatment plans. More than half of applicants were denied last year, according to Health and Human Services Department spokesperson Mindy Michaels.

Indiana’s Family and Social Services Administration, which runs its Medicaid program, declined an interview and said it could not comment on individual cases, like Brader’s.

Brader worries the additional red tape will cause her to lose Medicaid again. She said she was temporarily kicked off the program in 2019 for failing to meet the state’s work rules when Indiana said her work-study job didn’t count as employment.

“Anytime I have tried to receive help from the state of Indiana, it has been a bureaucratic nightmare,” she said.

As states await federal guidance, Kristi Putnam, a senior fellow at the conservative Cicero Institute and former secretary of the Arkansas Department of Human Services, which oversees the state Medicaid program, said even if a state creates an extensive list of qualifying “medically frail” conditions, the line must be drawn somewhere.

“You can’t possibly create a policy for exemptions that will catch everything,” she said.

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New Work Requirement Adds Red Tape to Missouri’s Snarled Food Aid System

Samantha Liss — Mon, 01 Dec 2025 10:00:00 +0000

WARRENTON, Mo. — Distributing food stamps soon could get even harder for Missouri’s food aid system, which a federal judge has already called “broken and inaccessible.”

States depend heavily on federal funds to operate their food stamp programs, which help feed about 42 million people nationwide. But a new federal law has restructured the nation’s food assistance, requiring more people to work to qualify for aid and shifting more of the program’s cost onto states over the next decade. Meanwhile, many Americans are struggling to afford groceries, and state governments are straining to help them.

More than a year ago, for example, a federal judge ruled that Missouri’s food aid system was “overwhelmed,” had wrongly denied assistance to applicants, and had caused many to go hungry as a “direct result of the system’s inadequacy.” The judge, Douglas Harpool, ordered the state to fix the problems.

Despite the court order, not much has changed, according to a �鶹Ů�� Health News analysis of state performance metrics.

Missouri’s ongoing problems foreshadow the trouble that lies ahead for state food aid programs nationwide. Food assistance advocates have said Missouri is just one example of a nationwide problem in which strained state systems struggle to deliver timely aid. For example, low-income people in Alaska have while the state has spent years trying to fix the problem.

Last year, then-U.S. Agriculture Secretary Tom Vilsack sent letters to 44 governors urging swifter application processing and greater accuracy in determining benefits.

The administrative snarls come on top of concerns about funding during the recent federal government shutdown. The Trump administration refused to use emergency funds to keep the food aid program running, and food benefits lapsed for millions of people, including in Missouri, on Nov. 1 as the shutdown dragged into its fifth week. Two federal judges ordered the Trump administration to tap emergency funds for the program.

The shutdown ended Nov. 12, and Missouri said its SNAP recipients began receiving their full benefits three days later. Meanwhile, as Thanksgiving approached, were still being reported in some states.

Even after the shutdown, states will have to do more with fewer resources. Republicans’ One Big Beautiful Bill Act slashes billions in federal funding to the food aid program and pushes more of the administrative and financial burden to states.

The bill President Donald Trump signed in July axes $187 billion over the next decade from the Supplemental Nutrition Assistance Program, commonly referred to as food stamps, or SNAP. That represents a 20% cut, according to the Congressional Budget Office.

One of the most significant and immediate changes requires more people to work to qualify for aid. The change will cause at least 2.4 million Americans to lose aid, according to from the bipartisan Congressional Research Service. The analysis predicts many people will lose their benefits because the work requirements will make applying more difficult.

Expanding work requirements will harm some of the nation’s most vulnerable people, said , who leads food aid strategies at the left-leaning Center on Budget and Policy Priorities.

But the conservative , a group that has worked to advance similar policies in states, says the requirement is necessary to preserve assistance for the “truly needy.”

‘Undisputed’ Strains in Missouri

Some Missourians were already struggling before Trump signed the bill.

Kelly Thweatt, 64, said she received a notice in the mail that her food benefits had been cut back. She didn’t understand why, because her income hadn’t changed, she said recently outside a SNAP office 60 miles west of St. Louis.

After she pays for her spot at a mobile home park in Warrenton, she said, she’s left with about $300 each month from Social Security. The roughly $300 in SNAP benefits she had received every month kept her afloat.

Thweatt will be subject to the new federal work requirement because she’s not yet 65.

More than are at risk of losing some amount of food aid because of the new work requirement, which went into effect Nov. 1.

For Thweatt, finding a job may prove difficult. She’s been out of the workforce for nearly 20 years.

Food aid provides a lifeline to more than 650,000 Missourians — that’s more than eight sold-out crowds at Arrowhead Stadium in Kansas City, where the NFL’s Chiefs play. The program helps feed 20% of Missouri’s children every month, according to the Missouri Foundation for Health, a nonprofit philanthropic organization. (The foundation provides financial support to �鶹Ů�� Health News.)

The recent federal changes will require more seniors, parents, veterans, homeless people, and former foster care youths to clear additional administrative hurdles to get food aid, .

Patrick McKelvey, executive director of the Gateway Food Pantry in Arnold, Missouri, unloads a recent grocery delivery. (Samantha Liss/�鶹Ů�� Health News)

For years, thousands of Missourians have struggled to tap into food assistance, largely because applicants must complete an interview, over the phone or in person. But many Missourians can’t get through to a state staffer.

Applicants have spent hours waiting on hold or in line outside state offices, according to a lawsuit filed in 2022 in federal court. At times, so many people have been waiting on hold that the phone system started hanging up on people, the lawsuit says.

Some Missouri SNAP offices are staffed by only a single employee, according to Harpool’s May 2024 order, adding to the strain.

In a statement provided to �鶹Ů�� Health News, the Missouri Department of Social Services said that because demand varies by location, it may be appropriate to have a single staffer in some places.

In Warrenton, makeshift phone booths line the walls of the food aid office. People sit at a cubicle with a desk and use a phone to complete interviews with officials elsewhere. A sign sitting on the floor asks applicants to “please be patient with our progress” as the state works on technology improvements.

According to Harpool’s order, the “evidence is undisputed” that Missouri’s food aid system has “unacceptable wait times” and that thousands of calls “cannot be completed.” These problems put Missourians at risk of losing aid “each and every time” they apply for food benefits, the judge wrote. To stay in the program, most households need to periodically submit documents and complete interviews.

A �鶹Ů�� Health News analysis of Missouri SNAP reports showed the same problems persist more than a year later. In the 16 months after the judge’s order, nearly half of all the applications that were denied were rejected at least partly because no interview was completed, according to data the state submitted to the court as part of the order. That indicates the state’s system is failing the most vulnerable, the judge has said.

In an order released in May of this year, Harpool found that Missouri failed to show significant improvement and that its performance deteriorated by some measures. The state hadn’t documented adding a single staffer or investing any additional resources to process applications faster, Harpool wrote.

Missouri’s Department of Social Services said the state legislature has provided money to hire temporary workers in other areas, freeing up staff to process SNAP applications.

To complete the required interviews for food aid, the agency said, it makes multiple attempts to reach applicants once an application is received.

, an attorney with National Center for Law and Economic Justice who represented Missourians in the case, said, “These are your neighbors, these are your kids’ classmates who are going hungry when the system doesn’t work.”

Trouble Ahead

Roughly 68% of the state’s food aid recipients are children, adults over 60, or people with a disability, according to the Missouri Foundation for Health. Many who can work already do.

, the food security policy manager with Empower Missouri, an organization working to eradicate poverty in the state, said Missouri lacks the money and the will to fix its food aid system.

Woody and other advocates fear the federal changes will erode the nation’s most powerful defense against hunger.

“For a state like Missouri that is already struggling to operate the program, these new rules couldn’t come at a worse time,” said Bolen, of the Center on Budget and Policy Priorities.

Nelson Berra, senior manager at the Gateway Food Pantry in Arnold, Missouri, organizes a recent grocery delivery. (Samantha Liss/�鶹Ů�� Health News)

Missouri foreshadows the trouble that lies ahead for other states, he said. Like Missouri, many states are reluctant to fund their food aid programs. And now they’ll be forced to use state dollars to fill the gaps left by the federal cuts, which “sets states up to fail,” Bolen said.

Supporters of the changes see it differently. U.S. House Speaker Mike Johnson previously described the cost shift to states as “modest” and said it’s necessary to reduce fraud. States “don’t have enough skin in the game,” ahead of the budget bill’s passage.

Still, if states do not come up with the money to fill the gap, Bolen said, they’ll be left with two options: Make it harder for people to qualify for SNAP, or end the program entirely.

For Thweatt, the change comes at a particularly hard moment. A few months ago, she lost her life partner of three decades, leaving her reeling and struggling to afford the basics. She does not turn 65 until April, which means she’s subject to the expanded work requirement until then and may have to show she has a job to maintain the $220 in monthly food benefits she has left. The state will apply the work rules to her case when she’s up for renewal, state officials said. Thweatt’s car needs repairs and its license plates are set to expire, she said. She doesn’t have the money to address either problem.

She’s selling everything that she can, including an antique bedroom set, to afford necessities, she said.

“I can satisfy myself with a bag of chips per day,” Thweatt said. “So if that’s what I need to do, that’s what I need to do.”

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The Nation’s Largest Food Aid Program Is About To See Cuts. Here’s What You Should Know.

Katheryn Houghton — Fri, 31 Oct 2025 19:29:14 +0000

The Trump administration’s overhaul of the nation’s largest food assistance program will cause millions of people to lose benefits, strain state budgets, and pressure the nation’s food supply chain, all while likely hindering the goals of the administration’s “Make America Healthy Again” platform, according to researchers and former federal officials.

Permanent changes to the Supplemental Nutrition Assistance Program are coming regardless of the outcome of at least two federal lawsuits that seek to prevent the government from cutting off November SNAP benefits. The lawsuits challenge the Trump administration’s refusal to release emergency funds to keep the program operating during the government shutdown.

A federal judge in Rhode Island ordered the government to use those funds to keep SNAP going. A Massachusetts judge in a separate lawsuit also said the government must use its food aid contingency funds to pay for SNAP, but gave the Trump administration until Nov. 3 to come up with a plan.

Amid that uncertainty, food banks across the U.S. braced for a surge in demand, with the possibility that millions of people will be cut off from the food program that helps them buy groceries.

On Oct. 28, a vanload of SpaghettiOs, tuna, and other groceries arrived at Gateway Food Pantry in Arnold, Missouri. It may be Gateway’s last shipment for a while. The food pantry south of St. Louis largely serves families with school-age children, but it has already exhausted its yearly food budget because of the surge in demand, said Executive Director Patrick McKelvey.

Gateway Food Pantry prepared for a surge in demand amid uncertainty about whether the federal government shutdown would halt funding for the nation’s largest federal food aid program. (Samantha Liss/�鶹Ů�� Health News)

New Disabled South, a Georgia-based nonprofit that advocates for people with disabilities, announced that it was offering one-time payments of $100 to $250 to individuals and families who were expected to lose SNAP benefits in the 14 states it serves.

Less than 48 hours later, the nonprofit had received more than 16,000 requests totaling $3.6 million, largely from families, far more than the organization had funding for.

“It’s unreal,” co-founder Dom Kelly said.

The threat of a SNAP funding lapse is a preview of what’s to come when changes to the program that were included in the One Big Beautiful Bill Act that President Donald Trump signed in July take effect.

The domestic tax-and-spending law cuts $187 billion within the next decade from SNAP. That’s a nearly 20% decrease from current funding levels, according to the Congressional Budget Office.

The new rules shift many food and administrative costs to states, which may lead some to consider withdrawing from the program, which helped about 42 million people buy groceries last year. Separate from the new law, the administration is also pushing states to limit SNAP purchases by barring such things as candy and soda.

All that “puts us in uncharted territory for SNAP,” said Cindy Long, a former deputy undersecretary at the Department of Agriculture who is now a national adviser at the law firm Manatt, Phelps & Phillips.

The country’s first food stamps were issued at the end of the Great Depression, when the poverty-stricken population couldn’t afford farmers’ products. Today, instead of stamps, recipients use debit cards. But the program still buoys farmers and food retailers and prevents hunger during economic downturns.

The CBO estimates that will lose food assistance as a result of in the budget law, including applying work requirements to more people and shifting more costs to states. Trump administration leaders have backed the changes as a way to limit waste, to , and to .

This is the biggest cut to SNAP in its history, and it is coming against the backdrop of rising food prices and a fragile labor market.

The exact toll of the cuts will be difficult to measure, because the Trump administration that measures food insecurity.

Here are five big changes that are coming to SNAP and what they mean for Americans’ health:

1. Want food benefits? They will be harder to get.

Under the new law, people will have to file more paperwork to access SNAP benefits.

Many recipients are already required to work, volunteer, or participate in other eligible activities for 80 hours a month to get money on their benefit cards. The new law to previously exempted groups, including homeless people, veterans, and young people who were in foster care when they turned 18. The expanded work requirements also apply to parents with children 14 or older and adults ages 55 to 64.

, if recipients fail to document each month that they meet the requirements, they will be limited to three months of SNAP benefits in a .

“That is draconian,” said Elaine Waxman, a senior fellow at the Urban Institute, a nonprofit research group. About 1 in 8 adults reported having lost SNAP benefits because they had problems filing their paperwork, according to .

Certain refugees, asylum-seekers, and other lawful immigrants are cut out of SNAP entirely under the new law.

A shopping cart inside the pantry. Patrick McKelvey, executive director of the pantry, exhausted the last of its annual food budget to help meet demand, which has surged amid expected losses of federal food aid. (Samantha Liss/�鶹Ů�� Health News)

2. States will have to chip in more money and resources.

The federal law drastically increases what each state will have to pay to keep the program.

Until now, states have needed to pay for only half the administrative costs and none of the food costs, with the rest covered by the federal government.

Under the new law, states are on the hook for 75% of the administrative costs and must cover a portion of the food costs. That amounts to an estimated median cost increase for states of more than 200%, according to by the Georgetown Center on Poverty and Inequality.

A �鶹Ů�� Health News analysis shows that a single funding shift related to the cost of food could put states on the hook for an additional $11 billion.

All states participate in the SNAP program, but they could opt out. In June, nearly wrote to congressional leaders warning that some states wouldn’t be able to come up with the money to continue the program.

“If states are forced to end their SNAP programs, hunger and poverty will increase, children and adults will get sicker, grocery stores in rural areas will struggle to stay open, people in agriculture and the food industry will lose jobs, and state and local economies will suffer,” the governors wrote.

3. Will the changes lead to more healthy eating?

The Trump administration, through its “Make America Healthy Again” platform, has made healthy eating a priority.

Health and Human Services Secretary Robert F. Kennedy Jr. has championed the restrictions on soda and candy purchases within the food aid program. To date, to limit what people can buy with SNAP dollars.

Federal officials previously blocked such restrictions, because they were difficult for states and stores to implement and they boost stigma around SNAP, according to . In 2018, the first Trump administration to ban sugar-sweetened drinks and candy.

A store may decide that hassle isn’t worth participating in the program and drop out of it, leaving SNAP recipients fewer places to shop.

People who receive SNAP are no more likely to buy sweets or salty snacks than people who shop without the benefits, . Research shows that encouraging healthy food choices is than regulating purchases.

When people have less money to spend on food, they often resort to cheaper, unhealthier alternatives that keep them sated longer rather than paying for more expensive food that is healthy and fresh but quick to perish.

McKelvey and volunteer Nora Lane unload a vanload of groceries, including SpaghettiOs and tuna, which arrived Oct. 28. The pantry largely serves families with school-age children. (Samantha Liss/�鶹Ů�� Health News)

4. How will SNAP cuts affect health?

Advocacy organizations working to end hunger in the nation say the cuts will have long-term health effects.

Research has found that kids in households with limited access to food to have a mental disorder. Similarly, food insecurity is linked to .

Working-age people with food insecurity to experience chronic disease. That high blood pressure, arthritis, diabetes, asthma, and chronic obstructive pulmonary disease.

Those health issues come with costs for individuals. Low-income adults who aren’t on SNAP more a year on health care than those who are.

lived in households with limited or uncertain access to food in 2023.

5. What does this mean for the nation’s food supply chain?

SNAP spending directly boosts grocery stores, their suppliers, and the transportation and farming industries. Additionally, when low-income households have help accessing food, they’re more likely to spend money on other needs, such as prescriptions or car repairs. All that means that every dollar spent through SNAP generates at least $1.50 in economic activity, .

A report by associations representing convenience stores, grocers, and the food industry estimated it to comply with the new SNAP restrictions.

Advocates warn stores may pass the costs on to shoppers, or they may close.

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Senators Press Deloitte, Other Contractors on Errors in Medicaid Eligibility Systems

Rachana Pradhan — Fri, 10 Oct 2025 15:05:41 +0000

Senators have launched an inquiry into companies paid billions in taxpayer dollars to build eligibility systems for Medicaid, expressing concern that error-riddled technology and looming work requirements “will cause Americans to lose Medicaid coverage to this bureaucratic maze.”

The letters, dated Oct. 10, were sent to four companies and follow a �鶹Ů�� Health News investigation that exposed widespread issues in states using Deloitte-run systems to assess Medicaid eligibility for millions of people. Failures have resulted in the erroneous loss of health coverage and other vital safety-net benefits for low-income people. Malfunctions in those systems can cost millions and take years to fix.

As most states prepare to institute work requirements mandated by the tax and domestic spending law President Donald Trump signed in July, it is each company’s responsibility to build functioning systems, “rather than to prioritize their bottom line.”

Democratic senators Ron Wyden of Oregon, Elizabeth Warren of Massachusetts, and Raphael Warnock of Georgia, as well as Sen. Bernie Sanders (I-Vt.), sent the letters to several companies the Centers for Medicare & Medicaid Services identified as eligibility system contractors: Deloitte, GDIT, Gainwell Technologies, and Conduent.

“They’re essentially health care middlemen that are in the business of red tape, and they profit when Americans don’t get health care,” Wyden, the top Democrat on the Senate Finance Committee, which oversees Medicaid, said in an interview.

“They’ve got a history of poor performance when it comes to determining eligibility or in helping Americans enroll in Medicaid,” Wyden said. “Without stronger oversight and real accountability, these contractors are just going to get a jumbo windfall for creating systems that actually harm Americans trying to get health care.”

Spokespeople for the four companies did not provide comments for this article.

As of June, were enrolled in Medicaid, according to CMS.

A handful of states operate their own Medicaid eligibility and enrollment systems, but most rely on contractors to build and run them. �鶹Ů�� Health News found that Deloitte, a global consultancy that generated in fiscal year 2025, dominates this slice of government business. Twenty-five states have awarded Deloitte contracts for eligibility systems. The agreements, in which the company commits to design, develop, implement, or operate state-owned systems, are worth at least $6 billion, dwarfing any of its competitors.

Kinda Serafi, a partner at Manatt Health, is advising states on how to reconfigure their systems to incorporate work requirements.

States are in a “major sprint” to make changes by 2027, she said, and they’re being “inundated” with pitches from vendors looking to secure contracts. It underscores the business opportunity these system changes represent for contractors.

“I think we have to really be vigilant to make sure that these vendors are implementing the requirements consistent with the law,” Serafi said.

Companies sign contracts with state governments, but the federal government pays the bulk of the cost. The federal government covers 90% of states’ costs to develop and implement state Medicaid eligibility systems and 75% of ongoing maintenance and operations expenses, according to federal regulations.

The Senate letters cite problems with Deloitte-run eligibility systems that �鶹Ů�� Health News identified. Among other issues, the Florida eligibility system erroneously cut benefits for new moms, and a problem in Kentucky prevented coverage applications from getting through online, which cost $522,455 and took 10 months to resolve.

“Unfortunately, these are just a few examples of third-party systems’ failure to serve their very function: to reliably and accurately determine an individual’s eligibility for Medicaid coverage and services,” the senators wrote.

The senators asked the companies to respond by Oct. 31 to their questions, such as whether companies’ contracts with states include financial incentives tying payment to the removal of Medicaid enrollees and whether the companies are penalized for coverage terminations made in error. The senators also demanded an accounting of the company’s lobbying expenditures for the past five years and protocols for making system changes.

By 2027, the Congressional Budget Office projected, based on an early version of the bill, will have to work or complete other qualifying activities for 80 hours a month to keep their benefits, unless they qualify for an exemption. The that 5.3 million enrollees will lose coverage by 2034.

The new work requirements are just one of several federally mandated Medicaid changes that are forcing states to adapt their eligibility systems.

Medicaid work requirements have been plagued with problems in the few states where they’ve been tested. Medicaid enrollees have been frustrated in trying to navigate byzantine rules and glitchy technology. Work requirements have also come at great cost.

Georgia has not adopted the ACA Medicaid expansion, which has granted benefits to millions of adults earning up to 138% of the federal poverty level. Instead, the state offers benefits to some people earning up to the poverty line who can prove they’re working or participating in similar activities for 80 hours a month. Nearly 110,000 Georgians had applied to the state’s Georgia Pathways to Coverage program through May, but only 9,157 people were enrolled as of mid-August. Under typical ACA expansion rules, for coverage, according to �鶹Ů��.

The Georgia program has cost $109 million, with $34 million spent on health benefits and more than $20 million allocated to marketing contracts, according to a �鶹Ů�� Health News analysis of state reports. Deloitte built Georgia’s eligibility system and is the primary consultant for the Pathways program.

Before Medicaid work requirements became federal law, Arizona also to federal regulators to launch its own version that would apply to roughly 190,000 people.

The state’s application provided insight into the types of system changes states may soon need to make to manage the new federal work requirement.

Arizona Medicaid officials said they would gather information on enrollees’ work hours, training, and education. The state’s eligibility system, which is operated by Accenture, would also need to check whether someone is exempt.

States are in the early stages of determining changes they need to make to implement work requirements.

Tessa Outhyse, a spokesperson for the California Department of Health Care Services, said the state expects upgrades to be processed “through the existing contractual change order process.” State contracts with eligibility companies often set aside millions to cover the cost of changes, but systems may require upgrades beyond the agreed-upon work.

In Missouri, upgrades are expected to cost roughly $33 million, according to a .

The state has a contract with private company RedMane to handle some of its Medicaid eligibility processing. Missouri plans to hire an additional contractor to ensure it properly institutes Medicaid work requirements, according to Baylee Watts, a spokesperson for Missouri’s Department of Social Services.

Medicaid eligibility contractors “have a lot of leverage and expertise to influence contracts, to win contracts,” Wyden said. “They can do a lot more, to the value of what we’re giving them.”

�鶹Ů�� Health News senior correspondent Renuka Rayasam and correspondent Sam Whitehead contributed to this report.

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Meet the Florida Group Chipping Away at Public Benefits One State at a Time

Katheryn Houghton — Thu, 08 May 2025 09:00:00 +0000

PHOENIX — As an Arizona bill to block people from using government aid to buy soda headed to the governor’s desk in April, the nation’s top health official joined Arizona lawmakers in the state Capitol to celebrate its passage.

Health and Human Services Secretary Robert F. Kennedy Jr. said to applause that was just the start and that he wanted to for other unhealthy foods.

“We’re not going to do that overnight,” Kennedy said. “We’re going to do that in the next four years.”

Those words of caution proved prescient when Arizona’s Democratic governor, Katie Hobbs, vetoed the bill a week later. Nevertheless, state legislation to restrict what low-income people can buy using Supplemental Nutrition Assistance Program benefits is gaining momentum, boosted by Kennedy’s touting it as part of his “” platform. At least 14 states have considered bills this year with similar SNAP restrictions on specific unhealthy foods such as candy, with Idaho and Utah passing such legislation as of mid-April.

Healthy food itself isn’t largely a partisan issue, and those who study nutrition tend to agree that reducing the amount of sugary food people eat is a good idea to avoid health consequences such as heart disease. But the question over the government’s role in deciding who can buy what has become political.

The organization largely behind SNAP restriction legislation is the Foundation for Government Accountability, a conservative policy think tank out of Florida, and its affiliated , which has used the name .

FGA has worked for more than a decade to reshape the nation’s public assistance programs. That includes SNAP, which federal data shows helps an average of afford food each month. It also advocates for ways to cut Medicaid, the federal-state program that connects to subsidized health care, including efforts in Idaho and Montana this year.

FGA’s proposals often seek to limit who taps into that aid and the help they receive. Those backing the group’s mission say the goal is to save tax dollars and help people lift themselves out of poverty. Critics argue that FGA’s proposals are a backdoor way to cut off aid to people who need it and that making healthy food and health care more affordable is a better fix.

Now, FGA sees more room for change under the Trump administration and the Kennedy-led health department, calling 2025 a “window of opportunity for major reform,” according to its .

A Vision for Limiting Government Benefits

Tarren Bragdon, a former Maine legislator, in 2011 to promote policies to “free millions from government dependency and open the doors for them to chase their own American Dream,” he said in a statement on FGA’s website. The main foundation as a staff of three with about $60,000 in the bank. As of 2023, it had a budget of more than $15 million and a team of roughly 64, according to the , and that’s not counting the lobbying arm.

The foundation got early funding from a grant from the , which has long backed right-leaning think tanks with ties to conservative activists including brothers Charles and David Koch.

FGA declined several interview requests for this article.

In recent years, the nonprofit a 2017 Mississippi law, the Jackson Free Press found, which intensified eligibility checks for public aid that for some applicants to qualify. It successfully pushed a 2023 effort in Idaho to for food benefits that health care advocates said led some recipients to lose access.

The same year, the group helped pass affecting eligibility in Iowa. Since those restrictions have taken effect, the has seen a record number of people show up at its pantries amid rising grocery prices and a scaling back of covid pandemic-era federal support, said Annette Hacker, a vice president at the nonprofit.

Part of the group’s strategy is to pass legislation state by state, with the idea that the crush of new laws will increase pressure on the federal government. For example, states can’t limit what food is purchased through SNAP without federal approval through a waiver process. And in the past, some of FGA’s efforts have stalled because states never got that approval.

Kennedy’s agenda now echoes some of FGA’s key messages, and he has said states can expect approval of their waivers. Meanwhile, congressional leaders are eyeing nationwide Medicaid cuts and work requirements, which FGA considers among its . The foundation also has a connection working inside the administration: Its former policy director, Sam Adolphsen, was President Donald Trump on domestic matters.

“We’re excited to fight from Topeka to Washington, D.C., as opposed to Washington, D.C., to Topeka,” , FGA’s state government affairs director, told Kansas lawmakers in February when testifying in support of SNAP legislation there.

Shaping State Policies

In the states, FGA has become known as a conservative “thought leader,” said Brian Colby, vice president of public policy for , a progressive nonprofit that provides analysis of state policy issues.

“Conservatives used to try to chop away at the federal budget,” Colby said. “These guys are doing it at the state level.”

In its 14 years, FGA has created a playbook to shape state policy discussions around public benefits behind the scenes. In Montana, retired Republican legislator , who worked with FGA, said not all of the think tank’s ideas split along party lines.

“They offer a buffet of options,” he said. “Their agenda is making government accountable; it’s in the name.”

He said besides drafting legislation, FGA provides talking points and data to help policymakers support their arguments. “They would go in and would say, ‘This is what Medicaid fraud is costing us,’” Smith said. “That would be the number you’d want to use in your bill.”

In January, FGA released a memo for states to “.” In February, that Wyoming Republican state Rep. said the group asked him to sponsor a SNAP restriction bill. The state sponsor of similar legislation in Missouri has repeated at least one of FGA’s talking points, as . In Arizona, Republican Rep. , who sponsored the SNAP legislation there, told �鶹Ů�� Health News FGA was behind that bill as well.

Opponents of such bills argue the proposals are not as simple as they sound. Amid debate on a SNAP bill in Montana, Kiera Condon, with the , testified the legislation would force grocery store workers to sort through what counts as soda or candy, “which could result in retailers not participating in SNAP at all.”

State lawmakers tabled the .

Montana legislators also easily passed a bill to extend the state’s Medicaid expansion program even after FGA began publishing a series of papers that asserted the Montana’s budget. FGA had presented data saying most Montanans on the program don’t work, which .

, who leads food aid strategies at the left-leaning Center on Budget and Policy Priorities think tank, said FGA has a pattern of proposing technical changes to existing laws and “unworkable work requirements” that cause people to lose benefits.

After working with policymakers in Kansas for a decade, FGA helped pass legislation that limited how long people can access cash assistance, added work requirements to SNAP, and banned the state from spending federal or state funds to promote public aid. Many of those changes came through 2015 legislation known as the “HOPE Act” drafted by FGA, .

, an advocacy organization for low-income Kansans, found the SNAP caseload sharply declined after the bill was enacted because of the new hurdles, dropping from 140,000 households in January 2014 to 90,000 as of January 2020.

“It’s death by a thousand cuts,” said Karen Siebert, an , a community food bank network in Kansas and Missouri. “Some of these FGA proposals are such complex policies, it’s hard to argue against and to explain the ripple effects.”

In 2024, the foundation produced more than two dozen videos featuring state politicians from across the nation touting the organization’s goals and dozens of research papers arguing public benefits are wrecking state budgets. FGA also has its to produce data out of the states it’s working to influence.

The organization released a list of 14 states it places to exert more influence. That included Idaho, where the group has four registered lobbyists in the state Capitol.

In 2023, FGA and successfully lobby for legislation there to require people receiving food aid to work at least 80 hours a month. The organization called the resulting law “landmark welfare reform” years in the making.

And this year, Idaho lawmakers passed more requirements for people enrolled in Medicaid who can work. FGA staffers worked with one of the co-sponsors of the legislation on a similar bill last year that failed, then again this year. A compromise bill passed with FGA’s backing, marking another victory for the foundation.

David Lehman, a lobbyist for the , which represents health organizations that have opposed FGA bills, said Idaho illustrates how FGA works with sympathetic lawmakers in conservative states to gain more ground.

“They’re pushing an already rolling rock downhill,” he said.

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