Medicaid work requirements due to begin across the United States in January will be enforced more strictly than federal rules demand in at least six Republican-led states, where recipients must provide medical evidence immediately if they claim they are too frail to work.
Arkansas, Idaho, Indiana, New Hampshire, North Carolina and Ohio have laws or policies barring people from simply declaring that a health condition prevents them from working, volunteering or studying.
The approach has raised concern among patient advocates, who warn that people could lose cover because they cannot afford to see a doctor or obtain the paperwork needed to prove their condition.
“Someone may not be able to work, but they can’t see a doctor because they can’t afford it. So they’re now applying for Medicaid,” said Jennifer Tolbert, director of state health policy and data at KFF. “But Medicaid is saying you need documentation from a provider.”
States divided over Medicaid work requirement evidence
The changes stem from President Donald Trump’s 2025 tax cut and policy law. They will affect up to 20 million low-income adults without children at home who receive Medicaid through the optional expansion adopted by 40 states and the District of Columbia.
The requirement does not apply in the 10 states, mostly in the South, that did not expand Medicaid. Those affected will generally have to work or volunteer for at least 80 hours a month, or attend school at least half-time, unless they qualify for an exemption.
The law includes exemptions for people considered medically frail, including those with substance use disorders, disabilities or serious medical conditions. But a rule published by the Centers for Medicare and Medicaid Services in June said a condition must “significantly impair” a person’s ability to work, volunteer or attend school to qualify.
Federal regulations allow states to accept a beneficiary’s own account of their condition for the first year. Some states, however, are moving immediately to require proof from a doctor, a disability award letter or other documentation.
From 2028, states will be allowed to accept self-attestation once each time someone enrols. After that, evidence will be required at least every 12 months to show that the condition remains and continues to prevent the person from working.
States are also expected to make greater use of third-party information, including workers’ compensation claims and prescription records. Conditions that do not appear in such databases may require certification from a doctor or other evidence.
Republicans backing tougher rules say documentation is needed to prevent fraud and protect the programme’s finances. Jonathan Ingram, vice-president of research and policy at the conservative Foundation for Government Accountability, has urged states not to rely on beneficiaries’ statements alone.
“Self-attestation is fraud-by-design,” he said. “It is a policy developed by bureaucrats to maximize enrollment at the expense of program integrity.”
Self-attestation is made under penalty of perjury, meaning people who lie can face criminal charges, although such prosecutions are rare.
Missouri Republican state representative Darin Chappell said he worked with the Foundation for Government Accountability on a proposed constitutional amendment requiring documentary evidence of employment or an exemption. The measure passed the state House but failed to receive a vote in the Senate, and Mr Chappell plans to revive it next year.
“If someone has a debilitating physical ailment — or mental ailment for that matter — something that prohibits them from working, that’s totally legitimate,” he said. “But we’re not taking anybody’s word for it. I don’t mean to shock you none, but people do tend to lie about such things.”
Advocates warn of people losing cover
Opponents of the stricter approach say the administrative demands could prevent eligible people from receiving help, particularly those seeking Medicaid because they already lack access to healthcare.
Nate Crippes, a lawyer at the Disability Law Center in Utah, where self-attestation can be used provisionally for the exemption, said: “The added paperwork, the hoops you have to jump through lead to coverage loss.”
He said most people in Utah’s Medicaid expansion group had a mental health or substance use disorder diagnosis, or both, creating an additional difficulty in proving that they were unable to meet the work requirement.
“We’re choosing to make people with health conditions jump through a bunch of hurdles,” said Camille Richoux, health policy director at Arkansas Advocates for Children and Families.
Advocates also question whether diagnosis codes alone can show how severely a person is affected. Lucy Dagneau, senior director of the state and local campaigns team at the American Cancer Society Cancer Action Network, said the codes did not indicate the seriousness of a condition.
Some people with a particular cancer might still be able to work, she said, while others with more advanced disease could not.
“Our fear is by that banning self-attestation, unfortunately, the state lawmakers who pass those laws are going to have a hand in more people losing coverage in their state than would have,” Ms Dagneau said.
The Medicaid changes are forecast to save the federal government $887 billion over the next decade, while leaving 7.5 million more people without health insurance, according to a 2025 Congressional Budget Office estimate.
States must also update their computer systems, in some cases at a cost of millions of dollars, before the new rules take effect. Several are already struggling to implement separate changes to the Supplemental Nutrition Assistance Programme, including expanded work requirements.
In Arizona, enrolment in the food programme fell by 55 per cent between April 2025 and April 2026, the largest drop in the country, with more than 400,000 fewer people receiving benefits. The state said the decline was largely linked to difficulties implementing new federal requirements, which led to higher call volumes and additional verification.
Democrats in 25 states are suing, arguing that the Medicaid rules are excessively harsh. The dispute is centred on whether preventing people from attesting to their own medical frailty will protect public funds or instead cut off qualified beneficiaries.
