"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?" – Tywon Pugh, a Missoula resident facing homelessness and health challenges.
New federal Medicaid work requirements, designed to push recipients towards employment, are poised to significantly impact individuals like Tywon Pugh, who face substantial barriers to consistent work due to chronic health conditions and unstable living situations. While proponents herald these regulations as a pathway to self-sufficiency, critics and affected individuals fear they will sever a vital lifeline for those most in need, potentially increasing homelessness and uninsurance. The stringent criteria and limited exemptions leave individuals like Pugh in a precarious position, questioning their ability to maintain essential healthcare coverage while grappling with complex personal crises.
Tywon Pugh’s struggle in Missoula, Montana, vividly illustrates the potential fallout of new federal regulations mandating that millions of Medicaid recipients prove they are working, volunteering, or pursuing education to retain their health coverage. These rules, which states have until January to implement, with Montana, Arkansas, and Nebraska already initiating them, present a formidable challenge for individuals facing multifaceted obstacles to employment. Pugh, a 46-year-old whose life was upended by the death of his wife last year, now contends with homelessness, a worsening alcohol dependency, and the persistent threat of seizures. His reliance on Medicaid for prescriptions that manage his condition, and for potential addiction treatment, is critical. However, the prospect of losing this coverage due to his inability to meet work requirements casts a long shadow over his efforts to regain stability.
The Trump administration’s framework for these work requirements includes exemptions for specific groups, such as individuals with disabilities, those over 64, pregnant individuals, and Native Americans. However, for those without a clear-cut qualification, the burden falls on them to demonstrate that they are too ill to work. Crucially, the administration has determined that homelessness is not a recognized medical condition and therefore does not automatically exempt individuals from these new stipulations. This stance directly contradicts the concerns of many, as several states, including Montana, Arizona, Kentucky, and Utah, had previously considered homelessness as a valid reason for exemption. Federal officials, however, have reiterated that states must adhere to the federally defined list of exemptions, leaving individuals experiencing homelessness in a vulnerable position.
The Centers for Medicare & Medicaid Services (CMS) declined to comment on the record regarding the specific challenges faced by homeless individuals, but confirmed the mandate to adhere to the federal exemption list. This policy comes at a time when homelessness in the United States has seen a significant increase. According to the Department of Housing and Urban Development (HUD), homelessness rose by 27% between 2013 and 2025, affecting approximately 746,000 people last year. While the exact number of homeless Medicaid enrollees is difficult to ascertain, data from 2023 indicates that a substantial portion, 55%, of patients receiving care through Health Care for the Homeless programs were enrolled in Medicaid, underscoring the deep connection between this population and the program.
Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, described the federal regulations as far more stringent than many states anticipated, even those supportive of work requirements. She noted that the strictness of the rules "took everyone by surprise." This sentiment is echoed by Mehmet Oz, who leads CMS, and who has framed these regulations as a "path to prosperity." He emphasized the need to encourage individuals to "try to work." However, the implementation of these rules has faced significant legal challenges. In June, 25 states, primarily led by Democrats, filed a lawsuit against the Trump administration, arguing that the medical frailty standard for exemptions would be excessively difficult for both enrollees to meet and for states to assess. The Congressional Budget Office projects that these work requirements could lead to an increase of over 5 million uninsured individuals nationwide by 2034.
Most states are scheduled to begin implementing these Medicaid work requirements in January. Montana, however, plans to initiate coverage terminations for enrollees unable to prove compliance with the work requirement as early as October. This accelerated timeline exacerbates the anxiety for individuals like Pugh, who are actively seeking employment but face significant hurdles. "I can’t get employed," Pugh stated, articulating the fundamental dilemma: "How am I supposed to survive?"
The divergence between state and federal exemption criteria extends beyond homelessness. Montana’s legislative proposals also aimed to include exemptions for individuals fleeing domestic violence and those caring for hospitalized family members, categories not explicitly listed in the federal guidelines. In 2019, Republican state Rep. Ed Buttrey, who supported Montana’s initial Medicaid work requirement bill, argued that these individuals, "due to a number of conditions, cannot meet those requirements." Federal officials contend that many homeless individuals could qualify for exemptions under the "too sick to work" provision. However, Montana’s system for automatically verifying medical exemptions through existing records is not yet fully operational, though the health department anticipates it will be in place by October. Until then, individuals not automatically exempted will have a 30-day window to provide proof of their inability to work.
For Tywon Pugh, the possibility of an exemption due to his seizures offers a glimmer of hope. Yet, the practicalities of accessing healthcare have become increasingly difficult. The past year, marked by the anniversary of his wife’s death, has been a constant struggle for survival. Finding a new place to sleep each night, losing his wallet and important documents during an outdoor encampment, and facing overbooked addiction treatment centers have all compounded his challenges. He is relying on sheer willpower to abstain from alcohol, a battle he describes as taking "one day at a time."
Dustin Goss, a case manager at Samaritan House, a homeless shelter in Kalispell, Montana, expresses deep concern that individuals eligible for exemptions may 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 supersede administrative tasks for those experiencing homelessness. Cassidy Kipp, who leads Samaritan House, noted that while clients often find employment once they achieve housing stability, meeting the new work requirements can still be problematic. Many begin with temporary, informal jobs that do not provide formal pay stubs, making it difficult to document their work activity.
Kaitlyn Bosshardt, a social worker at Partnership Health Center, a community health clinic in Missoula, has witnessed firsthand the escalating housing crisis. Rising rental costs are outpacing incomes, while affordable housing options and rental assistance remain scarce. Partnership Health Center, like approximately 1,400 other federally funded health centers nationwide, serves patients based on their ability to pay, ensuring continued care even for those who lose Medicaid. However, the financial sustainability of these clinics could be threatened if a significant number of patients lose their insurance coverage. Furthermore, these clinics typically do not offer specialized medical services.
During a sweltering June day, Pugh visited the Watershed Navigation Center, a refuge providing meals and medical care 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 avenues for addiction treatment. Pugh acknowledged the necessity of personal effort, telling Sidey, "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." Sidey offered encouragement, responding, "You got this, though, Tywon. You can do this."
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 from two job applications. In challenging moments, he draws strength from the memory of his wife, envisioning her urging him to remain calm and hopeful. "I just don’t wanna lose hope in the meantime," he said, underscoring the profound emotional and psychological toll of his current circumstances. The implementation of Medicaid work requirements, while intended to foster economic independence, risks creating a deeper crisis for individuals like Tywon Pugh, who are already navigating a complex web of health, housing, and financial instability.
