"I can’t get employed. How am I supposed to survive?" This question, posed by Tywon Pugh, a homeless man in Missoula, Montana, encapsulates the profound anxiety and uncertainty facing millions of Medicaid recipients under new federal work requirements. The regulations, designed to incentivize employment, risk severing the lifeline of health coverage for those already struggling with debilitating conditions, housing instability, and addiction, potentially pushing them further into a cycle of poverty and ill health.
The federal government’s recent implementation of work requirements for Medicaid recipients, a policy championed by the Trump administration, mandates that millions of individuals prove their engagement in work, volunteering, or education to maintain their health coverage. While states are granted until January to fully implement these checks, some, including Montana, Arkansas, and Nebraska, have already begun enforcing them. This sweeping change, intended as a "path to prosperity" according to former CMS leader Mehmet Oz, has ignited significant controversy, with critics arguing that it places an undue burden on vulnerable populations and could lead to a substantial increase in the number of uninsured Americans. The core of the debate lies in how these requirements define "work" and what constitutes a valid exemption, particularly for individuals whose disabilities, housing status, or health conditions make traditional employment an insurmountable challenge.
Tywon Pugh, a 46-year-old resident of Missoula, Montana, exemplifies the precarious situation many find themselves in. His life has been profoundly impacted by epilepsy, a condition that causes seizures, making sustained employment a significant hurdle. Recalling a past experience, Pugh shared, "They called me a ‘liability to the job site’," a manager’s dismissive assessment after a seizure led to his termination from a fast-food position. For years, his wife, who passed away last year, provided the financial stability and support he needed to manage his health and seek employment. Her death, however, precipitated a devastating cascade of events: Pugh became homeless, and his pre-existing struggle with alcohol addiction worsened, further complicating his seizure management. "When she died, my whole base was depleted," he reflected, underscoring the profound loss that stripped away his support system.
Medicaid has been instrumental in Pugh’s ability to manage his epilepsy, covering the cost of his essential prescriptions. This government-subsidized health coverage also holds the promise of addressing his addiction, a program he has attempted to access but found himself on a lengthy waitlist. Pugh’s primary aspiration is to regain his health and secure employment. However, a gnawing anxiety persists: the fear of losing the Medicaid coverage that is critical to his recovery and his journey back to self-sufficiency.
The federal regulations, finalized in the spring, present a complex web of stipulations for Medicaid enrollees. While certain groups are automatically exempted, including individuals with disabilities, those over 64, pregnant individuals, and Native Americans, others without clear-cut qualifications must demonstrate their inability to work due to illness. Crucially, the federal government 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 several states, including Montana, Arizona, Kentucky, and Utah, had previously proposed including homelessness as an exemption category. However, federal officials have maintained that states must adhere to the federally defined list of exemptions. The Centers for Medicare & Medicaid Services (CMS) declined to comment on the record but confirmed the necessity for states to align with the federal guidelines. This policy shift comes at a time when homelessness in the United States has seen a significant rise, increasing by 27% between 2013 and 2025, with approximately 746,000 individuals experiencing homelessness in the past year, according to data from the Department of Housing and Urban Development. Measuring the exact number of Medicaid enrollees who are homeless remains challenging, but a 2023 brief indicated that 55% of patients receiving services through Health Care for the Homeless programs were enrolled in Medicaid, highlighting the critical role of this coverage for this population.
Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, described the federal regulations as significantly more stringent than many states anticipated, even those generally supportive of work requirements. "It took everyone by surprise," Tolbert stated. This sentiment is echoed by the broader concerns surrounding the potential impact of these policies. The Congressional Budget Office projects that these work requirements could lead to an increase of over 5 million uninsured individuals nationwide by 2034.
Montana is among the states moving swiftly to implement these changes, with plans to begin disenrolling Medicaid beneficiaries who fail to meet the work requirement by October. This aggressive timeline exacerbates the anxiety for individuals like 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?" he questioned, articulating the dire consequences of losing coverage without a viable alternative.
The discrepancies between state-proposed and federal exemptions extend beyond homelessness. Montana had also intended to exempt individuals fleeing domestic violence and those caring for hospitalized family members, categories not included in the federal list. Republican state Representative Ed Buttrey, who previously supported Montana’s Medicaid work requirement bill, argued in 2019 that these individuals, due to various circumstances, are simply unable to meet the requirements. While federal officials suggest that many individuals experiencing homelessness might qualify for exemptions based on medical frailty, Montana’s system for automatically verifying such conditions through existing medical records is still under development, with the health department aiming to have it operational by October. Until then, individuals not automatically exempted will have a mere 30-day window to prove their eligibility.
For Tywon Pugh, the possibility of a health-related exemption offers a glimmer of hope. However, navigating the healthcare system has become increasingly difficult. The anniversary of his wife’s death has passed, and his daily reality involves finding new places to sleep outdoors each night. A recent incident of losing his wallet while camping, coupled with the overbooked addiction treatment centers accepting 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 shared, a testament to his resilience amidst profound 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 rightfully qualify 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 remarked, highlighting the immediate survival needs that supersede administrative tasks for those experiencing homelessness. Cassidy Kipp, director of Samaritan House, noted that while many clients find employment once they secure stable housing, meeting the new Medicaid requirements can still be challenging. Many initially find work in temporary or informal roles, such as odd jobs, which may not provide the documentation required to prove compliance with the work mandate.
Kaitlyn Bosshardt, a social worker at Missoula’s Partnership Health Center, has observed a growing number of individuals priced out of their long-term rentals due to soaring housing costs that outpace wage growth, while affordable housing options and rental assistance remain scarce. Partnership Health Center, like approximately 1,400 other federally funded health centers nationwide, provides care based on patients’ ability to pay. While these centers offer a safety net, even for those losing Medicaid, concerns remain that a significant loss of Medicaid coverage among their patient base could create substantial financial deficits for these clinics. Furthermore, these health centers generally do not offer specialized medical services, leaving a gap in care for individuals with complex health needs.
During a sweltering June day, Pugh visited the Watershed Navigation Center, a refuge for individuals without stable housing operated by Partnership Health. There, he met with his doctor, Atarah Sidey, who informed him that the neurology clinic managing his seizures had dismissed him after he missed three appointments. Sidey referred him to another neurologist in Missoula and discussed strategies for accessing 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 in Sidey. "You got this, though, Tywon," she responded with encouragement.
Pugh has since connected with a social worker to assist him in maintaining his Medicaid coverage. By late July, he was awaiting an opening at a Missoula addiction treatment center and awaiting responses to two job applications. In challenging moments, he draws strength from the memory of his wife, imagining her reassuring him that things will improve. "I just don’t wanna lose hope in the meantime," he stated, a poignant expression of his enduring spirit in the face of overwhelming obstacles.
