"Millions of Americans reliant on Medicaid could lose coverage under new federal work requirements, jeopardizing access to critical healthcare and addiction treatment, especially for those experiencing homelessness or with chronic health conditions."
New federal regulations mandating that millions of Medicaid recipients demonstrate work, volunteer, or educational engagement to maintain their health coverage are poised to dramatically impact vulnerable populations, including individuals experiencing homelessness and those with chronic health conditions. While proponents herald these requirements as a pathway to economic independence, critics and healthcare advocates warn of unintended consequences, potentially leading to a surge in uninsured individuals and exacerbating existing health disparities. The stringent federal guidelines, which states are beginning to implement, leave little room for exemptions, placing individuals who are already struggling with basic needs and health management in a precarious position.
In Missoula, Montana, Tywon Pugh’s precarious situation serves as a stark illustration of the challenges posed by these new regulations. Pugh, 46, grapples with debilitating seizures that have historically made consistent employment a significant hurdle. He recounts a past dismissal from a fast-food job where his manager labeled him a "liability to the job site." The loss of his wife of ten years last year plunged him into homelessness, a crisis that subsequently worsened his alcohol dependency and complicated his seizure management. "When she died, my whole base was depleted," Pugh stated, highlighting the profound personal and financial devastation he has endured.
Medicaid currently provides essential prescription coverage for Pugh’s seizures and would fund an addiction treatment program he desperately seeks. However, a lengthy waitlist for such programs and the looming threat of losing his Medicaid coverage due to the new work requirements cast a long shadow over his efforts to regain stability. "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 expressed, articulating the deep-seated anxiety many in similar circumstances face.
The federal government finalized regulations in the spring that require millions of Medicaid beneficiaries to prove they are working, volunteering, or attending school to retain their coverage. States have until January to implement these checks, with Montana, Arkansas, and Nebraska already having initiated the process. The Trump administration’s framework for these requirements includes exemptions for individuals with disabilities, those over 64, pregnant individuals, and Native Americans. However, those without a clear-cut qualification, such as age or documented disability, must prove they are medically unable to work. Crucially, the administration has determined that homelessness itself is not a medical condition and therefore does not qualify as an automatic exemption.
This stance has drawn criticism from advocates who note that homelessness significantly impedes an individual’s ability to meet work requirements. While many conservative policymakers support such measures, some states, including Montana, Arizona, Kentucky, and Utah, had previously proposed policies that would have included homelessness as a valid exemption. Federal officials, however, have maintained that states must adhere to the federal list of permissible exemptions. The Centers for Medicare & Medicaid Services declined to comment on the record but confirmed that states are bound by the federal government’s established exemptions. This policy comes at a time when homelessness in the U.S. has seen a significant increase. According to data from the Department of Housing and Urban Development, homelessness rose by 27% between 2013 and 2025, with approximately 746,000 individuals experiencing homelessness in the past year.
The exact number of homeless individuals enrolled in Medicaid is difficult to ascertain, but the reliance on public insurance among this population is substantial. In 2023, a study found that 55% of patients receiving medical or behavioral health services through Health Care for the Homeless programs were enrolled in Medicaid. Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, noted that the federal regulations are considerably more stringent than many states anticipated, even those that were amenable to work requirements. "It took everyone by surprise," Tolbert remarked.
Mehmet Oz, leading CMS at the time, characterized the regulations as a "path to prosperity" during a press conference in June, emphasizing the administration’s objective to encourage employment. However, the policy has faced significant legal challenges. In June, 25 states, primarily led by Democratic governors, filed a lawsuit against the Trump administration, arguing that the medical frailty standard would be excessively difficult for enrollees to meet and for states to administer. Projections from the Congressional Budget Office suggest that these work requirements could lead to an increase of over 5 million uninsured individuals nationwide by 2034.
While most states are slated to begin implementing these requirements in January, Montana has announced an earlier start date, intending to begin disenrolling Medicaid beneficiaries in October if they cannot demonstrate compliance. This accelerated timeline exacerbates concerns for individuals like Pugh, who face immediate threats to their healthcare access.
The disparity between state and federal exemption lists extends beyond homelessness. Montana’s lawmakers had also intended to exempt individuals fleeing domestic violence and those caring for hospitalized family members, categories not included in the federal exemptions. Republican state Rep. Ed Buttrey, who supported Montana’s initial Medicaid work requirement bill in 2019, previously stated that these individuals, due to various circumstances, are unable to meet the requirements.
Federal officials have suggested that many individuals experiencing homelessness might qualify for exemptions under the "too sick to work" provision. However, the infrastructure for automatically verifying such medical conditions through existing records is still under development in many states, including Montana. While the Montana Department of Public Health anticipates having such a system in place by October, individuals not automatically exempted would have a limited 30-day window to provide proof of their medical inability to work.
For Tywon Pugh, the possibility of qualifying for a health-related exemption hinges on his ability to navigate a system that is proving increasingly challenging. Accessing healthcare appointments has become a significant obstacle over the past year. The anniversary of his wife’s death, coupled with the daily struggle of finding a safe place to sleep, has taken a toll. A recent incident where he lost his wallet and essential documents while camping further compounded his difficulties. The overwhelming demand at addiction treatment centers accepting Medicaid patients forces him to rely solely on his willpower to combat his alcohol dependency. "I’m taking it one day at a time," he shared, reflecting his daily struggle.
Dustin Goss, a case manager at Samaritan House, a homeless shelter in Kalispell, Montana, expressed concerns that individuals eligible for exemptions could become ensnared in bureaucratic red tape. "You can’t really worry about getting paperwork done when you don’t know where you’re eating today," Goss observed, underscoring the immediate survival needs that often overshadow administrative tasks. Cassidy Kipp, who leads Samaritan House, noted that while many clients find work once they achieve stable housing, meeting the new requirements can still be problematic. She highlighted that many begin with temporary or informal jobs, such as performing odd jobs for cash, which do not generate pay stubs required for verification.
Kaitlyn Bosshardt, a social worker at Partnership Health Center in Missoula, has witnessed firsthand the escalating housing crisis, with rising rents outpacing wages and a shortage of affordable housing and rental assistance. Partnership Health Center, one of approximately 1,400 federally funded health centers nationwide, provides care on a sliding scale based on income. While these centers can continue to serve patients even if they lose Medicaid, a significant reduction in Medicaid enrollment could strain their financial sustainability. 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 resource center for individuals experiencing homelessness, run by Partnership. 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 Missoula 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 fears of a dire future. "You got this, though, Tywon," she responded, offering words of encouragement. "You can do this."
Pugh has since connected with a social worker to assist with maintaining his Medicaid coverage. By late July, he was awaiting an opening at a Missoula addiction treatment center and had applied for two jobs. In moments of doubt, Pugh finds solace in the memory of his wife’s comforting words, urging him to remain calm and hopeful. "I just don’t wanna lose hope in the meantime," he stated, his voice tinged with a resilient determination to persevere.
