"The new Medicaid work requirements, while intended to foster self-sufficiency, are creating significant hurdles for individuals with chronic health conditions and those experiencing homelessness, threatening their access to essential healthcare and jeopardizing their precarious stability."
The federal government’s implementation of new regulations requiring millions of Medicaid beneficiaries to demonstrate work, volunteer, or educational engagement to maintain their health coverage is presenting a complex and often insurmountable challenge for many vulnerable individuals. These requirements, finalized in spring and slated for full implementation by January, are particularly burdensome for those grappling with disabilities, chronic illnesses, and homelessness, populations that often struggle to meet the stringent criteria. While exemptions exist for certain groups, the narrow definition of qualifying conditions and the administrative burden of proving medical frailty are leaving many, like Tywon Pugh, in a precarious position where essential healthcare access is threatened by their inability to secure or maintain employment.
Tywon Pugh, a 46-year-old resident of Missoula, Montana, exemplifies the profound difficulties faced by individuals caught in the crosshairs of these new Medicaid regulations. His life has been significantly impacted by epilepsy, a condition that triggers seizures, making sustained employment a formidable challenge. He recalls a manager at a fast-food restaurant dismissing him as a "liability to the job site" after a seizure disrupted his work. For years, Pugh relied on his wife to manage their finances and household during periods of unemployment. However, her death last year shattered his support system, leading to homelessness and exacerbating his struggle with alcohol dependency, which in turn complicates his seizure management.
"When she died, my whole base was depleted," Pugh shared, underscoring the devastating impact of losing his primary caregiver and emotional anchor. While Medicaid currently covers his seizure medication, the same government-subsidized health coverage would also fund an addiction treatment program he desperately needs. Yet, he has been placed on a waiting list for this crucial service, highlighting a system already strained and potentially unable to accommodate the influx of individuals seeking help. Pugh’s primary objective is to regain his health and return to work, but he harbors significant anxiety about maintaining the Medicaid coverage that is vital to his recovery and eventual employment.
The federal government’s finalized regulations mandate that states begin verifying enrollees’ engagement in work, volunteering, or education by January, though Montana, Arkansas, and Nebraska have already initiated these checks. The Trump administration’s framework offers exemptions for individuals with disabilities, those over 64, pregnant individuals, and Native Americans, among others. However, for those without a clear-cut qualification based on age or disability status, proving they are too sick to work is the only pathway to an exemption. Crucially, the administration has explicitly stated that homelessness is not considered a medical condition and therefore does not qualify as an automatic exemption from these new requirements.
This stance has been a point of contention, as many conservative policymakers have long advocated for work requirements in public assistance programs. Several states, including Montana, Arizona, Kentucky, and Utah, had previously proposed policies that would have included homelessness as a valid reason for exemption. However, federal officials have maintained that states must adhere strictly to the federally defined list of exemptions. In a statement to KFF Health News, the Centers for Medicare & Medicaid Services (CMS) declined to comment on the record but confirmed that states are bound by the federal government’s exemption criteria. This policy stands in stark contrast to the rising tide of homelessness in the United States, which, according to the Department of Housing and Urban Development (HUD), increased by 27% between 2013 and 2025, affecting approximately 746,000 individuals last year.
Quantifying the number of homeless individuals enrolled in Medicaid is challenging, but data from the National Health Care for the Homeless Council indicates that in 2023, 55% of patients receiving medical or behavioral health services through Health Care for the Homeless programs were enrolled in Medicaid. This suggests a significant overlap between the homeless population and Medicaid beneficiaries, underscoring the potential impact of the new work requirements.
Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, noted that the federal regulations are far more stringent than many states anticipated, even those that had embraced the concept of work requirements. "It took everyone by surprise," Tolbert stated, reflecting the widespread sentiment among state officials and advocacy groups. The rationale behind these regulations, as articulated by CMS leader Mehmet Oz during a press conference in June, was to provide a "path to prosperity" by encouraging individuals to seek employment. "We need to get people to try to work," Oz asserted.
However, these regulations have faced significant legal opposition. In June, 25 states, primarily led by Democratic governors, filed a lawsuit against the Trump administration, arguing that the medical frailty standard for exemptions would be exceedingly difficult for enrollees to meet and for states to administer. Projections from the Congressional Budget Office estimate that these work requirements could lead to an increase of over 5 million uninsured individuals nationwide by 2034.
As most states prepare to implement these changes in January, Montana is set to begin disenrolling Medicaid recipients who fail to comply with the work requirements as early as October. This accelerated timeline in Montana adds an immediate layer of urgency for individuals like Tywon Pugh. "My Medicaid is still active, but when are they gonna cut that off from me? I can’t get employed. How am I supposed to survive?" Pugh questioned, articulating the profound existential threat posed by the potential loss of his health coverage.
The divergence between state and federal exemption lists extends beyond homelessness. Montana lawmakers had also planned to exempt individuals fleeing domestic violence and those caring for hospitalized family members – categories not included in the federal list. Republican state Rep. Ed Buttrey, who championed Montana’s initial Medicaid work requirement bill in 2019, argued that these individuals, "due to a number of conditions, cannot meet those requirements." While Buttrey did not comment for this article, his past statements highlight a legislative intent to accommodate individuals facing significant life challenges. Federal officials maintain that many individuals experiencing homelessness could qualify for exemptions based on medical frailty. However, Montana’s system for automatically verifying such conditions through existing medical records is still under development, with the health department anticipating its readiness by October. Until then, individuals not automatically exempted will have a 30-day window to present evidence of their inability to work.
For Tywon Pugh, the possibility of qualifying for a medical exemption due to his epilepsy offers a glimmer of hope. Yet, the practicalities of accessing healthcare have become increasingly difficult. The anniversary of his wife’s death has recently passed, and his daily life involves finding new places to sleep outdoors each night. A recent incident where he lost his wallet and crucial documents while camping further complicated his situation. Compounding these challenges, the limited availability of addiction treatment centers that accept Medicaid patients has forced him to rely solely on his willpower to abstain from alcohol. "I’m taking it one day at a time," he stated, a testament to his resilience amidst immense adversity.
Dustin Goss, a case manager at Samaritan House, a homeless shelter in Kalispell, north of Missoula, shares Pugh’s concerns. He worries that individuals who are genuinely eligible for exemptions will become ensnared in bureaucratic complexities. "You can’t really worry about getting paperwork done when you don’t know where you’re eating today," Goss observed, highlighting the immediate survival needs that often overshadow administrative tasks for those experiencing homelessness.
Cassidy Kipp, who leads Samaritan House, added that while many clients find employment once they secure stable housing, meeting the new Medicaid requirements can still be a hurdle. Many begin with temporary, informal jobs, such as assisting with clean-outs, which do not provide traditional pay stubs necessary for proving employment. Kaitlyn Bosshardt, a social worker at Missoula’s Partnership Health Center, a federally qualified health clinic, has witnessed firsthand the growing number of individuals priced out of their homes due to escalating housing costs and stagnant wages. The scarcity of affordable housing and rental assistance further exacerbates this crisis.
Partnership Health Center, like approximately 1,400 other health centers nationwide, operates on a sliding scale based on patient income, ensuring that even those who lose Medicaid can still receive care. However, representatives from these health center organizations have cautioned that a significant loss of Medicaid coverage among their patient population could create substantial financial deficits. Furthermore, these clinics often lack the capacity to provide specialized medical services.
During a particularly hot June day, Pugh visited the Watershed Navigation Center, a Partnership-funded refuge for individuals without stable housing. His doctor, Atarah Sidey, informed him that the neurology clinic managing his seizures had discharged him after he missed three appointments. Sidey referred him to another neurologist in town and discussed potential avenues for addiction treatment. "It’s just that if I don’t make the effort at changing, it ain’t gonna happen and I’m gonna end up found on the side of the road somewhere," Pugh confided to Sidey, expressing his deep-seated fear of succumbing to his circumstances. "You got this, though, Tywon," she responded with encouragement, a sentiment Pugh acknowledged with a nod. "You can do this."
Pugh has since connected with a social worker to help navigate the complexities of maintaining his Medicaid coverage. By late July, he was awaiting an opening at a Missoula addiction treatment center and awaiting responses from two job applications. In moments of despair, he draws strength from the memory of his wife, imagining her urging him to remain calm and hopeful. "I just don’t wanna lose hope in the meantime," he stated, a poignant reflection of his enduring struggle for stability and well-being.
