The Paperwork Problem: How Medicaid Work Requirements Are Set to Repeat Health Equity's Biggest Recent Mistake
Author: Hannah Worby, MPH – Director, Research and Insights
In May 2026, Nebraska became the first state to require Medicaid expansion enrollees to prove they're working, in school, or otherwise "engaged" for 80 hours a month — or lose their coverage.¹ Montana and Arkansas followed on July 1. Now, every other state has until January 1, 2027.² By the time full enforcement hits, an estimated 20 million people will be subject to documentation requirements most of them have never had to meet before.³
During the 2023–2024 Medicaid "unwinding," when states resumed eligibility checks after pandemic-era protections lapsed, three-quarters of coverage losses were procedural — people who were still eligible but got tripped up by paperwork, outdated addresses, or renewal forms they never received. Black and Hispanic enrollees lost coverage this way at roughly twice the rate of white enrollees.⁴ Today, work requirements will repeat that mechanism and will make it a monthly burden for the enrollee.
The politics around work requirements rest on an assumption that large numbers of Medicaid enrollees are choosing not to work. The evidence doesn't support that. Researchers modeling the rollout found that between 19% and 37% of people who are already working will still lose coverage because they can't reliably document 80 hours a month, every month, to a state system.⁵ Add in people who qualify for an exemption (caregivers, students, people with disabilities) but don't have that status verified on file, and the population at risk widens considerably.
Independent analysis of the federal government's own implementation rule found it likely understates coverage losses, in part because it assumes more people will successfully claim exemptions than prior state-level experience supports.¹ The pattern from Kentucky, Arkansas, and other states that piloted work requirements years ago was consistent: the barrier was proving employment to a bureaucracy, often through an online-only portal, at a moment when broadband access itself splits sharply along racial and geographic lines.
The unwinding period in 2023-2024 also produced a clear answer for what works. States that invested in automated "ex parte" renewals — verifying eligibility through existing wage, tax, and SNAP data instead of requiring enrollees to resubmit paperwork — cut procedural denials substantially. A federal partnership with four states raised ex parte renewal rates by over 21 percentage points and dropped procedural denials by more than 8 points, without loosening any actual eligibility standard.⁶
The same tools can apply here: verifying work and exemption status through existing state and employer data before ever putting the burden on the enrollee; funding community health worker and navigator outreach in the languages and channels people actually use; and requiring states to report disenrollment data by race and ethnicity, so we're not relying on advocacy groups to reconstruct the pattern after the fact. None of this requires changing who is eligible. It only requires states to stop treating "didn't complete the paperwork" as a synonym for "doesn't qualify."
Every state currently building its work-requirement system is making an implementation choice, whether or not it frames it that way. Automate verification and invest in outreach, and coverage losses fall mostly to people who are genuinely ineligible. Default to manual documentation and minimal outreach, and coverage losses fall disproportionately on the same communities the unwinding already hit hardest. The rule is being written into state systems this year. The pattern doesn't have to repeat — but nothing about the current rollout guarantees it won't.
Sources
Urban Institute, The New Federal Rule on Medicaid Work Requirements Understates Likely Coverage Losses and Overestimates Potential Employment Gains (Aug. 2026)
Healthcare Dive, Nebraska rolls out Medicaid work requirements, putting tens of thousands at risk of coverage losses (May 2026)
Center for Health Care Strategies, A Summary of Federal Medicaid Work Requirements (June 2026)
Journal of the American Medical Association / PMC, Racial and Ethnic Disparities in Medicaid Disenrollment After the End of the COVID-19 Public Health Emergency (2024)
Urban Institute / Robert Wood Johnson Foundation, Millions Could Lose Medicaid Coverage Due to New Rules (Mar. 2026)
Health Affairs, Interventions To Automate Medicaid Renewals Reduce Procedural Denials And Increase Coverage (Nov. 2025)
