Since the passage of HR1 (the “One Big Beautiful Bill Act”) in July 2025 many health advocates have been worried about the implications of the bill’s “work requirements” for individuals to maintain their Medicaid coverage.¹ Medicaid is the primary expected source of payment for more than 40 percent of emergency department (ED) visits.² The new work requirements—scheduled for national implementation in 2027—are expected to significantly limit access to Medicaid, thereby threatening patients’ access to care and the financial stability of EDs nationwide.

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Emergency departments operate under the unfunded mandate of the Emergency Medical Treatment and Labor Act (EMTALA), which functions as a unique moral force in the U.S. health care system to evaluate and care for all patients who present to the ED, regardless of ability to pay. Given that such a high proportion of patients who seek ED care rely on Medicaid for their insurance, experts are concerned that the procedural barriers and additional paperwork inherent to the Medicaid work requirements’ provision will limit access to needed coverage.

Millions of Americans may lose coverage due to new requirements such as regular documentation of employment, volunteering, or schooling that will be required at least every six months.³ In 2022, long before the One Big Beautiful Bill Act, ACEP passed a resolution opposing mandatory work requirements for Medicaid beneficiaries.⁴ Older adults age 50 to 64 are likely to experience the greatest negative impact. These patients are both more likely to have trouble finding work and to have complex medical needs. Caregivers are also likely to be affected, further limiting the ability of patients to be cared for at home or in residential settings, which are less resource intensive as compared with the ED setting.

The emergency medicine-specific provisions of the new law can be found at ACEP’s website. ⁵ In brief, the work requirements will apply to Medicaid enrollees in the 40 states that have expanded Medicaid to non-disabled adults and will take effect on January 1, 2027, unless a state applies for an extension, or like Nebraska, launch these requirements even sooner (May 2026).⁶

Why Were Work Requirements Included in the Bill?

Work requirements for Medicaid were likely motivated by the belief that those receiving Medicaid benefits should be “deserving” in some way (e.g., disabled, pregnant, or caring for children), or are demonstrating some type of economic contribution to society. However these beliefs are not evidence-based. Sixty-four percent of Medicaid enrollees are already working, at least part time. An additional 29 percent of Medicaid enrollees are not working due to full-time caregiving responsibilities, illness or disability, or they are full-time students.⁷

There was also likely some hope among legislators that work requirements will place the obligation for health insurance onto the employer, thus reducing the government’s obligation to provide access to health coverage. Lastly, legislators also faced a pragmatic need to identify sources of savings in the legislation to offset tax breaks and other federal expenditures. The expected reduction in Medicaid spending, because of limiting coverage through mechanisms such as work requirements, was one solution that gained traction as the bill made its way through Congress.

Learning from the Past

Now that work requirements will be expected more broadly, it is important to learn from the experience of states that implemented work requirements even before the law was passed.

Case Study: Arkansas

Work requirements for Medicaid were first implemented in Arkansas in mid-2018 as part of the state’s Section 1115 waiver, which supported its Medicaid expansion program and was known as Arkansas Works.⁸ As part of the state’s Medicaid expansion, adults age 30 to 49 earning up to 138 percent of the federal poverty level of income (FPL) (~$28,000/year for a family of three in 2018) were required to engage in 80 hours per month of work or other qualifying activities, such as being full-time students, engaged in vocational training, or caregivers, and exempted those who were mentally or physically frail. Even those who received automatic exemptions had to renew them every other month, or they would lose that exemption.

Enrollees were required to report their work hours each month through an onerous process where failure to do so for three months in a row would result in the loss of Medicaid benefits for the remainder of the calendar year. Studies showed no increase in employment or hours worked in 2018 and 2019 because of the policy.⁹ In March 2019, just six months after the work requirements were implemented, a federal judge blocked the state from enforcing the requirements because the state “did not address concerns that would lead a substantial number of Arkansas residents to be disenrolled from Medicaid.” During Arkansas’ seven-month experience with Medicaid work requirements, more than 18,000 beneficiaries (one in four of those are subject to the requirement) were disenrolled from the state’s Medicaid program. Moreover, due to the burdensome process of reporting work hours and low public awareness, fewer than 1,500 people, or 11 percent of those who lost coverage in 2018, were able to re-enroll in Medicaid after losing coverage in 2019.

Case Study: Georgia

In July 2023, Georgia began a highly touted, but very limited, expansion of its traditional Medicaid program to cover individuals earning up to 100 percent of the FPL who reached a similar 80-hour monthly threshold of work, volunteer activity, study, or vocational rehabilitation. The Georgia work requirement did not have exemptions for parents or other full-time caregivers. Although the state estimated that nearly 240,000 people would qualify for Medicaid and that nearly 75,000 people would enroll in the first two years, the actual numbers have been much lower. In its first two years, the Georgia Pathways to Coverage Section 1115 waiver enrolled fewer than 12,000 people.^10,11

Within its first year, the program’s administrators had a backlog of more than 16,000 cases. Like Arkansas’ burdensome approach, Georgia initially required enrollees to submit monthly work hours with monthly certification but then switched to only recertifying or checking the submitted hours annually, citing administrative burden. Had the state pursued the Affordable Care Act’s Medicaid expansion to cover individuals up to 138 percent of the FPL without work requirments, Georgia would have received $1 billion in federal funds for two years which would have offset cost increases associated with expansion, drawn a 90 percent federal match for newly eligible enrollees, and cost the state less than $500 per new enrollee. Instead, Pathways has cost Georgia more than $86.9 million in combined state and federal funds and costs nearly $13,000 per person.^12,13

Traditional Medicaid versus Medicaid Expansion

Medicaid generally covers individuals who quality for Supplemental Security Income, individuals with disabilities, pregnant women, and low-income children and parents. The federal minimum eligibility levels for children and pregnant individuals are effectively set at 138% of the federal poverty level (FPL), but in the 10 states that did not expand Medicaid, adults without dependent coverage are not eligible for Medicaid coverage regardless of their income level. In the 40 states that expanded Medicaid following the passage of the Affordable Care Act in 2010, the median coverage level for parents and adults without dependent children is 138% FPL, compared to states have not adopted the ACA expansion, the median eligibility for parents was 33% FPL.^14,15

Implications for Federal Implementation

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By implementing Medicaid work requirements nationwide, there may be real short-term cost savings accrued to the U.S. federal government. However, the long-term cost of limiting access to coverage may outweigh these short-term gains. The Congressional Budget Office projected work requirements would reduce federal spending by $326 billion over 10 years.^3,16 The bulk of these potential savings results from an additional 4.8 million people losing Medicaid coverage by 2034 because of work requirements.^3,16 These potential savings must be weighed against the harms of decreased access to insurance and loss of preventive medical care that will affect those individuals unable to comply with the actual work or with the administrative burden of submitting documentation under Medicaid work requirements.

In the absence of insurance, prior Medicaid beneficiaries will have few options for care, likely becoming uninsured. The most likely options will be seeking primary care in the ED setting or delaying treatment for conditions otherwise preventable and treatable in the outpatient setting. The experiences of Arkansas and Georgia serve as cautionary tales, highlighting that bureaucratic barriers, not lack of effort, often drive disenrollment. Work requirements do not bode well for Medicaid recipients, the population as a whole, or emergency physicians and departments that face an unfunded mandate to keep the doors open to care for the nation’s most vulnerable Americans.

Dr. Medoff is an assistant professor of emergency medicine at Emory University. He is the director of Emory’s Health Equity, Advocacy, and Policy track for residents and fellows and co-leads the ACEP State Legislative and Regulatory Committee’s Medicaid objective.

Dr. Scott is a fourth-year emergency medicine resident at the University of Washington. She holds an MPhil in Public Health from the University of Cambridge, MD from Harvard Medical School, and PhD in Health Policy from Harvard University. Dr. Scott co-leads the ACEP State Legislative and Regulatory Committee’s Medicaid objective and is a 2026 EMRA-ACEP Health Policy Academy Fellow.

Dr. Cochran-Caggiano is an emergency medicine and EMS physician at Dartmouth Health and the Dartmouth Geisel School of Medicine. He previously served on NYACEP Government Affairs Committee for five years, completed an advocacy and policy internship with the American College of Physicians New York Chapter and joined the ACEP State Legislative and Regulatory Committee in 2024.

Dr. Kornas is the medical director of the emergency department and chief of staff at AdventHealth Avista. She has a passion for advocacy with a particular focus on the intricacies of Medicaid administration. She currently serves as Colorado state advocacy lead for her company, US Acute Care Solutions, and is a past president of Colorado ACEP.

Dr. Hsieh is an assistant professor at the University of California at Los Angeles School of Medicine, Harbor–UCLA Medical Center, and Chief Medical Officer at Contra Costa Health Plan.

Dr. Mitchiner is recently retired from Trinity Health Ann Arbor, where he practiced emergency medicine for 36 years, and from Chelsea Hospital in Chelsea, Michigan, where he was on the emergency department staff for 28 years. He also served as a clinical faculty member at the University of Michigan Medical School.  Dr. Mitchiner is also past president of the Michigan College of Emergency Physicians. He has served as Chair of ACEP’s State Legislative and Regulatory Committee, as a member of ACEP’s Federal Government Affairs Committee, and has participated on ACEP task forces covering EMTALA, emergency department crowding, health care and the uninsured, alternative payment methods, and single-payer/health care financing.

References

1. House Bill 1 (H.R. 1). 119th Congress (2025–26). U.S. Congress.
   https://www.congress.gov/bill/119th-congress/house-bill/1/text [congress.gov]
2. Centers for Disease Control and Prevention. QuickStats: percentage of emergency department visits with Medicaid as the primary expected source of payment among persons aged <65 years, by race and ethnicity—National Hospital Ambulatory Medical Care Survey, United States, 2011–2021. MMWR Morb Mortal Wkly Rep. 2023;72. doi:10.15585/mmwr.mm7231a6
3. Hinton E, Diana A, Rudowitz R. A Closer Look at the Medicaid Work Requirement Provisions in the One Big Beautiful Bill. KFF. June 20, 2025. https://www.kff.org/medicaid/issue-brief/a-closer-look-at-the-medicaid-work-requirement-provisions-in-the-big-beautiful-bill/. Updated July 30, 2025: A Closer Look at the Work Requirement Provisions in the 2025 Federal Budget Reconciliation Law. KFF. Accessible at: https://www.kff.org/medicaid/a-closer-look-at-the-work-requirement-provisions-in-the-2025-federal-budget-reconciliation-law/.
4. American College of Emergency Physicians. Board Approves New Policy Statements on Gender Diversity, Interference in Patient/Physician Relationship, Liability and More. ACEP Now. Published August 12, 2022. Available at: https://www.acep.org/home-page-redirects/latest-news/board-approves-new-policy-statements-on-gender-diversity-interference-in-patientphysician-relationship-liability-and-more.
5. American College of Emergency Physicians. Emergency Medicine-Specific Provisions of the “One Big Beautiful Bill Act”. Available at: https://www.acep.org/siteassets/new-pdfs/advocacy/acep-summary-of-em-specific-obbba-provisions.pdf.
6. Nebraska Department of Health and Human Services. Medicaid work requirements. Accessed April 26, 2026. https://dhhs.ne.gov/Pages/WorkRequirements.aspx
7. Tolbert J, Cervantes S, Rudowitz R, and Burns A. Understanding the Intersection of Medicaid and Work: An Update. KFF. Published May 30, 2025. Available at https://www.kff.org/medicaid/understanding-the-intersection-of-medicaid-and-work-an-update/.
8. Medicaid.Gov. Arkansas Works. Accessible at: https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/81021
9. Gangopadhyaya A, and Karpman M. The Impact of Arkansas Medicaid Work Requirements on Coverage and Employment: Estimating Effects Using National Survey Data. Health Serv Res. 2025; e14624. https://doi.org/10.1111/1475-6773.14624.
10. Georgia Pathways to Coverage. Accessible at: https://pathways.georgia.gov/.
11. Georgia Department of Community Health. GeorgiaPathways.org. Accessible at: https://www.georgiapathways.org/data-tracker
12. Coker M. Georgia Touts Its Medicaid Experiment as a Success. The Numbers Tell a Different Story. ProPublica and The Current. Published February 19, 2025. Accessible at: https://www.propublica.org/article/georgia-medicaid-work-requirement-pathways-to-coverage-hurdles.
13. Chan L. Georgia’s Pathways to Coverage Program: The First Year in Review. The Georgia Budget & Policy Institute. Published October 29, 2024. Accessible at: https://gbpi.org/georgias-pathways-to-coverage-program-the-first-year-in-review/
14. Rudowitz R, Priya Chidambaram, Jennifer Tolbert, et al. Who Is Covered by Medicaid? – Medicaid 101. KFF. October 8, 2025. Accessed April 22, 2026. https://www.kff.org/medicaid/health-policy-101-medicaid/?entry=table-of-contents-who-is-covered-by-medicaid
15. Cervantes S, Clea Bell, Jennifer Tolbert, Anthony Damico. How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion? KFF. February 25, 2025. Accessed April 22, 2026. https://www.kff.org/medicaid/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/
16. Congressional Budget Office. Estimated Budgetary Effects of H.R. 1, the One Big Beautiful Bill Act. Published June 4, 2025. Available at https://www.cbo.gov/publication/61461.