Last year, congressional Republicans enacted the most significant entitlement reforms in recent memory. These changes are critical since Medicaid’s explosive growth in recent years has turned the program into an open-ended, $1 trillion-a-year entitlement.

Creating modest work requirements for able-bodied adults — with clear exemptions for vulnerable recipients — puts Medicaid on a more sustainable fiscal trajectory and ensures taxpayer dollars remain focused on caring for the needy.

Work requirements refocus a key safety net on its intended mission: serving as a last-resort lifeline for those who are unable to care for themselves. The mandate requires able-bodied adults to spend just 20 hours a week working, studying, or volunteering. No longer can young, healthy men in the prime of their working years waste their time playing video games on the taxpayers’ dime. Americans over the age of 64, people with disabilities, and parents of children under 13 years of age are entirely exempt from the work mandate. These groups will see no change in their benefit status.

The Trump administration is currently implementing these work requirements, which the Congressional Budget Office estimates will save taxpayers $326 billion over 10 years. But with the midterm elections around the corner, even sensible reforms can become targets for political demagoguery. A coalition of Democratic attorneys general sued the administration earlier this summer to block the rollout of the work mandate, and congressional Democrats recently warned that the requirements would harm the “sickest Americans.”

Sensationalist political theatre is nothing new during an election year. But much of the rhetoric surrounding work requirements bears little resemblance to the policy itself. Critics have warned that Republicans are putting pregnant mothers and children at risk of losing their health insurance, yet neither group is subject to the mandate.

After Obamacare expanded Medicaid eligibility to able-bodied adults earning up to 138% of the federal poverty level, targeted work requirements are necessary to protect access to care for Medicaid’s vulnerable enrollees.

Under Obamacare, states receive significantly higher federal dollars for the able-bodied expansion population than for recipients such as low-income children or adults who are disabled or pregnant. This funding structure incentivized state Medicaid agencies to expand enrollment among able-bodied adults. This process increased federal spending while shifting resources away from at-risk recipients the program was originally intended to serve. Fueled by Obamacare’s perverse incentives, Medicaid expenditures surged by 88% between 2014 and 2024. Moreover, the financial sweetener to maximize enrollment among able-bodied adults has compounded the program’s longstanding problem with improper payments. Today, Medicaid ranks among the top five government programs for payment errors. In fiscal year 2025, the federal government reckons payment mistakes in Medicaid totaled just over $37 billion.

Notwithstanding the hysterics of campaign-season rhetoric, work requirements will improve the well-being of Medicaid beneficiaries. A 2025 study found that 62% of able-bodied adults on Medicaid reported no earned income. As enrollees enter the labor force and obtain employer-sponsored coverage, the Department of Health and Human Services estimates work requirements could lift up to 2.9 million people out of poverty.

And yet, the biggest benefits of work requirements will not be financial. Regular employment plays a critical role in maintaining physical and mental health, and one study published in the medical journal Epidemiology and Psychiatric Sciences even recommends work as a “critical mental health intervention.”

In the past, work mandates in other safety net programs have shown that administrative loopholes and inconsistent enforcement can significantly undermine congressional intent. For example, federal law requires able-bodied adults without dependents to work, study, or volunteer at least part-time to remain enrolled in the Supplemental Nutrition Assistance Program (SNAP). Yet, states have routinely exploited geographic-area waivers to exempt local recipients from federal mandates.

Fortunately, the administration is taking the necessary steps to ensure Medicaid’s work requirements won’t be another paper mandate. For example, the medical frailty standard represents a thoughtful approach to maintaining program integrity. Considering functional limitations rather than just a vague medical diagnosis reduces opportunities for enrollees to abuse the medical frailty exemption.

Getting healthy, working-age adults off government welfare rolls and into the labor force, where they can access employer-sponsored health insurance, frees up scarce federal resources for Medicaid’s truly vulnerable recipients. The Trump administration should stand firm in the face of campaign-season attacks and ensure the implementation of these work requirements remains faithful to congressional intent.

***

Alex Ciccone is Policy and Government Affairs Manager at National Taxpayers Union.

Menu

No More Free Rides: Inside The Fight Over Medicaid Work Requirements