Donate
Very close up view of a form that reads "Medicaid Eligibility" with partial view of a stethoscope on it.
HomePublicationsBlogEight Million Medi-Cal Enrollees at Risk of Losing Health Coverage If Congress Imposes Work Requirements

Eight Million Medi-Cal Enrollees at Risk of Losing Health Coverage If Congress Imposes Work Requirements

March 25, 2025 - 
Nari Rhee,Laurel LuciaandMiranda Dietz

The budget blueprint passed in February by the House of Representatives includes $880 billion in cuts over 10 years from the agency that oversees Medicaid, which pays for health care for 80 million low-income people across the U.S.[1] While the details have yet to be worked out, one cut being discussed involves work requirements for “able-bodied adults” on Medicaid, which the Congressional Budget Office estimates could reduce federal spending by about $100 billion by reducing the number of people enrolled.

Other states’ experiences demonstrate that work requirements do not increase employment among enrollees. Instead, their onerous documentation requirements increase administrative costs and reduce enrollment and access to care, including for people who are already working or otherwise should be exempt. For policymakers interested in encouraging employment, this reduction in care access is counterproductive: research shows that access to health care improves individuals’ ability to find and keep jobs.

Medicaid work requirements would particularly harm California and other states that have relied on the program to improve health care access among children and low-income adults, including workers without employer-sponsored health insurance. In 2024, about 38% of Californians were enrolled in the state Medicaid program (Medi-Cal), of whom 8.2 million were working-age non-disabled adults, according to estimates from the Center on Budget and Policy Priorities (CBPP).

In fact:

  • 63% of adult Medi-Cal recipients aged 19-64 already work for pay, and another 29% are unable to do so due to school, family caregiving responsibilities, or an illness or disability, according to KFF. Medi-Cal provides health insurance for at least one out of every five working Californians.
  • Evidence indicates that Medicaid work requirements will not increase employment, but rather will significantly reduce health care access for low-income people—including workers—through burdensome and costly red tape.
  • CBPP estimates that 8.2 million Californians—Medi-Cal enrollees aged 19-64 who qualify for the program through non-disability pathways—would be at risk of losing coverage if a Medicaid work requirement were imposed. These 8.2 million Californians represent 56% of Medi-Cal enrollees and 35% of working-age adults in the state. Most of the adults at risk of losing coverage under potential work requirements are already working.

Most non-disabled adult Medi-Cal participants already work for pay or would be exempt  from a work requirement

According to the latest KFF estimates, among working-age adult Medi-Cal recipients who are not on federal disability benefits,[2] 42% work full-time, 21% work part-time, 8% attend school, and 14% take care of children or sick or disabled family members. Another 7% are currently unable to work due to an illness or disability. Only 8% cite other reasons for not working, such as retirement, inability to find work, or other reasons.[3]

In California and other states that opted to expand Medicaid to low-income working-age adults under the Affordable Care Act, the program plays a significant role in filling large voids in the job-based health insurance system, given that low-wage workers are less likely to have health insurance through their jobs (32%) than all California workers (54%). According to a UC Berkeley Labor Center analysis published by the California Health Care Foundation, at least one in five California workers are enrolled in Medi-Cal, and up to one in three in building services, food services, and agriculture.[4] These sectors have the lowest rates of access to employer-sponsored health insurance. Medi-Cal is also a critical safety net for workers who are between jobs, and the program supports workforce participation.

Medicaid work requirements can lead to a significant reduction in health insurance coverage among low-income adults, without increasing employment

While many states have applied for waivers to impose work requirements on Medicaid recipients, most have been struck down by the courts. This is largely because the intent of Medicaid expansion to working-age adults under the Affordable Care Act was to increase Americans’ access to health insurance, and the statute does not mention work requirements.[5] However, Arkansas’ and New Hampshire’s brief experiences with Medicaid work requirements are instructive.

In June 2018, Arkansas became the first state to implement a Medicaid work requirement. Adults aged 30-49 were required to certify each month that they worked 80 hours or more that month, participated in another qualifying activity such as job training or community service, or met criteria for pregnancy or a disability. Failure to meet certification requirements for three or more months would result in termination of coverage. Over 18,000 adults were removed from the program in just the first six months, prompting a federal judge to end the work requirement in March 2019.

A study of outcomes published in the New England Journal of Medicine found a 12% reduction in Medicaid coverage among Arkansas adults aged 30-49, with no evidence of increased employment. In addition, less than 5% of Medicaid participants in this age group did not meet work/community engagement requirements or exemption criteria, indicating that many eligible adults lost coverage. Most adults targeted by the policy had never heard of it, were confused about whether it applied to them, or had difficulty accessing assistance related to reporting requirements. A follow-up study of Arkansas found concerning short- and long-term consequences: at least half of those who lost coverage reported problems with delayed care, delayed medications, and medical debt.

New Hampshire imposed a stringent work requirement in June 2019, requiring Medicaid participants aged 19-64 to work at least 100 hours a month and to report those hours every month to remain in the program. The state offered a relatively narrow set of exemptions, primarily covering pregnant, disabled, or medically frail people, postpartum mothers (up to 60 days after giving birth), and caretakers of dependent children aged five and younger. Despite the state’s outreach efforts, the requirements were confusing to many participants, who had difficulty obtaining clarification from the state. After just two months, 17,000 beneficiaries—two-thirds of those covered by the new rules—became subject to disenrollment. Faced with this prospect, state officials temporarily suspended the work requirement. Federal courts subsequently terminated the program.

It is also worth noting that work documentation requirements increase administrative costs including significant costs related to IT systems, staff time for outreach and review reporting, and staff training. According to the Government Accountability Office, work requirements can cost hundreds of millions of dollars based on the experience in five states that are much smaller than California.

More than eight million Californians–including several million workers–would be at risk of losing coverage under work documentation requirements

By imposing a barrier to Medicaid enrollment through cumbersome requirements to document work hours or apply for an exemption, the potential impact of a work certification requirement extends far beyond current non-working enrollees who would not qualify for an exemption. Such requirements, including monthly work hours thresholds, can be particularly onerous for people who work multiple part-time jobs, perform freelance or consultant work, or do not have a consistent work schedule. The Center on Budget and Policy Priorities in Washington, DC, and the California Budget Policy Center both estimate that 8.2 million adults in California—non-disabled enrollees age 19-64 on Medi-Cal—would be at risk of losing coverage. They make up 56% of all Medi-Cal enrollees and 35% of all working-age adults in the state. Among those at risk are several million people already working for pay, given Census data on Medi-Cal enrollee workforce participation. In addition, students, caregivers, disabled people not on SSI, and others could lose coverage if they are unable to navigate the red tape.

Not all of these “at risk” Californians would lose coverage. However, we can expect that a significant number of people who technically meet Medicaid work requirements would be removed from Medi-Cal, with negative long-term consequences for their health and finances. The Urban Institute analyzed potential coverage losses from a 2023 House bill that would have imposed work requirements on adults aged 19-55 enrolled in Medicaid expansion under the ACA, based on the experiences of Arkansas and New Hampshire. The authors estimated that between 34% and 39% of expansion enrollees in the U.S. would lose coverage. They found that most adults who would lose coverage would be working or qualify for exemptions under the policy, but would be disenrolled due to reporting requirements. They also concluded that there would be a broader loss of coverage if work documentation requirements apply to other populations, such as non-disabled adults aged 55-64.

Importantly, the harms of a work documentation requirement would extend beyond working-age adults directly subject to work requirements. For example, research has shown that parents’ access to health insurance affects their children’s health. In addition, if caregivers must work to be eligible for health coverage, their aging family members or family members with disabilities could be at greater risk of institutionalization.

Conclusion

The vast majority of working-age California adults enrolled in Medi-Cal are already working, or are unable to do so due to school, family caregiving responsibilities, or an illness, disability, or inability to find work. Many working adults rely on Medi-Cal because of a lack of access to affordable employer-based coverage. Available evidence indicates that Medicaid work requirements will not increase employment, thereby failing to achieve the stated policy goal.

Medicaid work requirement policies would likely result in the termination of health care for millions of California adults, including many who are already working or exempt from the policy but would lose coverage due to the paperwork requirements. This loss of coverage not only threatens access to care and financial security for households that lose health coverage but would also reduce Medi-Cal revenue and increase uncompensated care for health care providers around the state, with negative financial impacts extending into local economies.

For estimates of participants at risk of losing Medi-Cal coverage due to work requirements by Congressional District see California Budget and Policy Center’s How Republican-Led Budget Cuts Could Impact Californians in Every Congressional District.

For more information related to Medicaid work requirements, see:

To understand which parts of the state would be most impacted by broader Medicaid cuts, see UC Berkeley Labor Center maps showing the number and percentage of all Californians enrolled in Medi-Cal by district and county–for all ages and for children and teens.

Endnotes

[1] The enrollment total includes the Children’s Health Insurance Program.

[2] Specifically, Supplemental Security Income and Social Security Disability Income recipients were excluded from the KFF analysis of non-disabled Medicaid recipients..

[3] While proposed Medicaid work requirements cover “able-bodied working-age adults”, they can be detrimental to disabled people who enrolled under ACA expansion and do not qualify for carve-outs for SSI and SSDI recipients.

[4] Survey data significantly under-count Medicaid enrollment compared to administrative data. The Labor Center data published  by CHCF reflects a conservative estimate of the share of workers participating in Medi-Cal, and the actual share could be significantly higher.

[5] Specifically, Title XIX. 42 U.S.C. § 1315(a). Work requirements are mentioned only once, in reference to TANF participants.