Yesterday, October 1, was the deadline in Montana. Since July, nearly 71,000 Montanans on Medicaid have been living under a new federal rule: to keep their coverage, they must show that they work, volunteer, or go to school. Montana started early. On January 1, most of the country joins it.
The rule comes from last year's federal budget law. It applies to adults ages 19 to 64 who get Medicaid through the Affordable Care Act's expansion, in 42 states and the District of Columbia, about 18.5 million people by the Congressional Budget Office's estimate. Each month, they must log 80 hours of work, community service, a work program, or at least half-time school, or earn at least 80 times the federal minimum wage, which is $580 a month. Parents of children 13 and under, pregnant and postpartum people, the medically frail, veterans with a total disability rating, and several other groups are exempt. The federal government issued the detailed rules on June 1. States must be ready by January 1.
The case for the rule is simple. "In an economy like this, if you're an able-bodied adult that's able to work, you really do need to step up," said Matt Regier, Montana's Republican Senate president. The CBO counts the requirement as the largest single source of federal Medicaid savings in the law, $326 billion over ten years.
My desk's question is narrower. Not whether people should work, but what happens to someone who does work and still can't prove it.
That is not a hypothetical. When Arkansas tried a work requirement in 2018, about 18,000 people lost coverage, a loss KFF attributes to the program's implementation difficulties. Montana's own rollout has already shown how easily it happens. A June 26 letter from the state health department told enrollees at one point that proof was due at their next renewal, expected in the spring, and further down, that paperwork was due "within 30 days." State officials told lawmakers the letters have since been made clearer. At a September 9 hearing, they said 20 of the 59 positions meant to process the work were filled. "The notices coming from the department are very, very confusing," said state Rep. SJ Howell, a Democrat.
This is the gap between a rule about work and a system built on paper. Not everyone can be checked automatically. The state has to match them against wage records or other databases, and when the data doesn't match, the burden shifts to the person. Most states plan to check every six months, at renewal. In a KFF survey, state officials estimated that data matching could verify 60% to 80% of current enrollees. The other 20% to 40% will be asked to prove it themselves. "The higher this manual reporting burden, the less people are going to do it," said Morgan Henderson, a researcher at the Hilltop Institute.
Washington has more than 600,000 people who will face the requirement for the first time, and they will also have to reapply twice as often. The state says an automated verification hub, built to use existing data so people don't have to send in paperwork, should help 400,000 of them keep coverage. Even with that, the governor's office projects at least 200,000 people will lose Apple Health by the end of 2027 because of the federal law.
That number deserves a slow read. Some of those people will be people the law intended to remove. Some will be people who met every requirement and missed a letter. The law does not distinguish between them; it only counts who is left.
Montana's deadline has passed. Ours is three months away. The number my desk will be watching next spring is not how many people on Medicaid work. It is how many of the ones who do are still covered.
