Millions of people who apply for Medicaid in the coming years will have to prove they鈥檝e 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 鈥 part of the GOP鈥檚 One Big Beautiful Bill Act, signed last July by President Donald Trump 鈥 don鈥檛 go far enough.
Indiana is leading that charge, with a new law that requires applicants to prove they鈥檝e 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鈥檝e been working just one month, the least cumbersome option under Trump鈥檚 signature tax-and-domestic-spending law. It instructs states to decide whether to require one, two, or three months of work history.
Like in Indiana, Republican Idaho lawmakers also approved a three-month requirement, and the state鈥檚 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.
鈥淣ormally, you would not see state legislators weighing in on these decisions,鈥 said Lucy Dagneau, a senior official with the American Cancer Society鈥檚 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鈥檚 Medicaid population. The rules generally wouldn鈥檛 apply to children, people 65 or older, or people with disabilities or serious health issues.
Typically, state administrators 鈥 not lawmakers 鈥 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 鈥 the longest period allowed under the federal law.
Republican state Sen. Chris Garten introduced a bill in January, saying it was needed to 鈥渁lign鈥 state law with the new federal Medicaid rules. He also pitched the bill as a way to crack down on 鈥渨aste, fraud, and abuse鈥 in public programs.
When ineligible people get enrolled, it robs 鈥渢he truly vulnerable Hoosier who actually needs the help,鈥 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.
鈥淚 think very few,鈥 Roob replied. 鈥淚t鈥檒l never be none.鈥
After hearing Roob鈥檚 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鈥檚 accusation a 鈥渇undamental mischaracterization鈥 of the bill.
Republicans have said imposing these limits protects the Medicaid program鈥檚 longevity.
鈥淲e believe in a safety net for our most vulnerable, not a hammock for able-bodied adults that choose not to work,鈥 Garten said. 鈥淏y tightening these screws, we ensure that our safety net remains sustainable.鈥
Indiana鈥檚 Medicaid enrollment is expected to decrease because of Garten鈥檚 legislation, according to an analysis from Indiana鈥檚 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.
鈥淚f the point is to get people engaged, the one month would do it,鈥 Mueller said.
Ultimately, he fears the law will harm Hoosiers with the greatest need for assistance. 鈥淭hey鈥檙e going to get tripped up by the bureaucratic hurdles.鈥
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 鈥渟ignificantly affect the number of people who lose coverage.鈥 State policy decisions will determine just 鈥渉ow intense the burden is,鈥 the left-leaning think tank found, and opting for a shorter look-back period 鈥渨ill enable more people to enroll.鈥
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 鈥渕ove people from dependency and give them back that dignity and pride of work.鈥
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 鈥渨orking mindset.鈥
Anna Meyer, owner of a small bakery in Columbia, Missouri, said the implication is that she and others on Medicaid are lazy. 鈥淚 have been working since I was 15 years old,鈥 she said. 鈥淚鈥檓 43 now.鈥
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.
鈥淚 work very hard,鈥 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, 鈥淥h, actually, health care is a privilege, and you have to earn it,鈥 she said.
of adults ages 19 to 64 on Medicaid already work, according to 麻豆女优. The reason many of the remaining adults on Medicaid are not working is that they are retired, serving as a caregiver, or too sick, 麻豆女优 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 鈥渟hort-term hardship,鈥 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鈥檚 vulnerable residents when they need coverage the most, particularly Missouri鈥檚 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鈥檚 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 鈥渧ery important in the life of a cancer patient or a cancer survivor,鈥 Kalmer said.