The Trump administration’s Medicaid overhaul has arrived, and it’s built around one idea: an 80-hour-a-month work requirement. Supporters call it a way to root out waste. The Centers for Medicare & Medicaid Services call it “community engagement.” In reality, the new rule is a paperwork machine tied in a bureaucratic bow.
The idea is that Medicaid is full of people who could work but won’t. This is fundamentally misguided. About 9 in 10 Medicaid recipients already work, study, have a disability, or care for a family member. There is no hidden army of slackers – just millions of people who rely on this coverage and an administration that pretends otherwise.
States have run this experiment. Arkansas tried it in 2018. More than 18,000 adults lost coverage before a federal court halted the program. Over 95% of people that lost their insurance actually met the requirement or qualified for an exemption. The losses were not primarily among those refusing to work, but rather individuals who lacked reliable internet access and could not use the online reporting portal. Confusion about the reporting system rose. Employment rates and community engagement did not.
The rationale behind the requirement focuses on savings, but running the system is not cheap. In 2023, Georgia launched a similar program, Georgia Pathways. In just two years, just over 8,000 individuals had enrolled in Medicaid, but the program cost over $100 million. Only 26% of that money went toward patient care. The rest went toward call centers, verification software, and staff to process appeals.
CMS wants to scale these failed experiments up. The Congressional Budget Office estimates the new rule will save taxpayers nearly $1 billion, with work-requirement disenrollment accounting for the largest share of “savings.” Arkansas and Georgia have already taught us where that money comes from. It does not come from people finally getting jobs or reducing fraud. It comes from people losing coverage while states are forced to spend millions on the infrastructure to make them lose it.
Every state has to build its system from scratch: new software, new call centers, and new personnel. That’s 43 replications of Arkansas’ and Georgia’s expensive, broken systems. These systems demand mountains of paperwork from disabled residents and caretakers, built to generate red tape rather than treat patients in need.
If the government actually wants to root out waste, it would start by asking why states are spending millions of dollars apiece on new paperwork systems instead of health care. Instead, they’re asking why caretakers, the disabled, and those in need missed a filing deadline. This is not a work requirement; it’s just an expensive guise of “personal responsibility” to strip health care access away from millions of Americans.
Rachna Edalur and Kaitlyn Castro are medical students in Austin and members of the national advocacy organization Physicians for a National Health Program (pnhp.org).
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This article appears in October 16 • 2026.