The nation’s first mandated work requirement for Medicaid recipients, approved by the Republican-led Congress and signed by President Trump, is expected to have a seismic effect in California.
One estimate from state health officials suggests that as many as 3.4 million people could lose their insurance through what Gov. Gavin Newsom calls the “labyrinth of manual verification,” which involves Medi-Cal recipients proving every six months that they are working, going to school or volunteering at least 80 hours per month.
“It’s going to be much harder to stay insured,” said Martha Santana-Chin, the head of L.A. Care Health Plan, a publicly operated health plan that serves about 2.3 million Medi-Cal patients in Los Angeles County.
She said that as many as 1 million people, or about 20% to 40% of its members, could lose their coverage.
The work requirement will be the first imposed nationwide in the six-decade history of Medicaid, the program that provides free and subsidized health insurance to disabled and low-income Americans.
It’s relatively uncharted territory, and it’s not yet clear how the rules will shake out for the 5.1 million people in California who will be required to prove that they are working in order to qualify for Medi-Cal, the state’s version of Medicaid.
After the 2026 midterm elections, millions of healthy adults will be required to prove every six months that they meet the work requirement in order to qualify for Medicaid. The new mandate spells out some exceptions, including for people who are pregnant, in addiction treatment or caring for children under age 14.
Democrats have long argued that work requirements generally lead to eligible people l osing their health insurance due to bureaucratic hurdles. Republicans say that a work requirement will encourage healthy people to get jobs and preserve Medicaid for those who truly need it.
“If you clean that up and shore it up, you save a lot of money,” said House Speaker Mike Johnson of Louisiana. “And you return the dignity of work to young men who need to be out working instead of playing video games all day.”
Only three U.S. states have tried to implement work requirements for Medicaid recipients: New Hampshire, Arkansas and Georgia. One study found that in the first three months of the Arkansas program, more than 18,000 people lost health coverage.
People can lose coverage a variety of ways, said Joan Alker, a Georgetown University professor who studies Medicaid. Some people hear that the rules have changed and assume they are no longer eligible. Others struggle to prove their eligibility because their income fluctuates, they are paid in cash or their jobs don’t keep good payroll records. Some have problems with the technology or forms, she said, and others don’t appeal their rejections.
Of the 15 million people on Medi-Cal in California, about one-third will be required to prove they are working, the state said. Those people earn very little: less than $21,000 for a single person and less than $43,000 for a household of four.
The state’s estimate of 3.4 million people losing coverage is a projection based on what happened in Arkansas and New Hampshire.
But those programs were brief, overturned by the courts and weren’t “a coordinated effort among the states to figure out what the best practices are,” said Ryan Long, the director of congressional relations at the Paragon Health Institute, a conservative think tank that has become influential among congressional Republicans.
Long said advancements in technology and a national emphasis on work requirements should make work verification less of a barrier. The budget bill includes $200 million in grants for states to update their systems to prepare, he said.
Arguments from liberal groups that people will lose healthcare are a “straw man argument,” Long said: “They know that the public supports work requirements for these benefits, so they can’t come out and say, ‘We don’t support them.’”
A poll by the health research group KFF found this year that 62% of American adults support tying Medicaid eligibility to work requirements.
The poll also found that support for the policy drops to less than 1 in 3 people when respondents hear “that most people on Medicaid are already working and many would risk losing coverage because of the burden of proving eligibility through paperwork.”
In June, Newsom warned that some Californians could be forced to fill out 36 pages of paperwork to keep their insurance, showing reporters an image of a stack of forms with teal and gold accents that he described as “an actual PDF example of the paperwork that people will have to submit to for their eligibility checks.”
Many Californians already are required to fill out that 36-page form or its online equivalent to enroll in Medi-Cal and Covered California, the state’s health insurance marketplace.
Experts say it’s too soon to say what system will be used for people to prove their work eligibility, because federal guidance won’t be finalized for months.
Newsom’s office directed questions to the Department of Health Care Services, which runs Medi-Cal. A spokesperson there said officials are “still reviewing the full operational impacts” of the work requirements.
“The idea that you are going to get a paper submission every six months, I’m not sure people have to do that,” Long said.
Georgia is the only state that has implemented a lasting work requirement for Medicaid. Two years ago, the state made healthcare available to people who were working at least 80 hours per month and earned less than the federal poverty limit (about $15,000 for one person or $31,200 for a household of four).
More than 100,000 people have applied for coverage since the program’s launch in July of 2023. As of June of this year, more than 8,000 people were enrolled, according to the state’s most recent data.
The Medicaid program has cost more than $100 million so far, and of that, $26 million was spent on health benefits and more than $20 million was allocated to marketing contracts, KFF Health News reported. Democrats in Georgia have sought an investigation into the program.
The Inland Empire agency that provides Medi-Cal coverage for about 1.5 million people in San Bernardino and Riverside counties estimated that 150,000 members could lose their insurance as a result of work requirements.
Jarrod McNaughton, the chief executive of the Inland Empire Health Plan, said that California’s 58 counties, which administer Medi-Cal, “will be the ones at the precipice of piecing this together” but haven’t yet received guidance on how the eligibility process will be set up or what information people will have to provide.
Will it be done online? Will recipients be required to fill out a piece of paper that needs to be mailed in or dropped off? “We don’t really know the process yet, because all of this is so new,” Naughton said.
In the meantime, he said, the health plan’s foundation is working to make this “as least burdensome as possible,” working to improve community outreach and connect people who receive Medi-Cal insurance to volunteer opportunities.
