Bold opening: Millions could lose coverage just to prove a point about work. And this is where the debate sharpens, because the real impact hits middle-aged adults the hardest.
Lori Kelley, a 59-year-old resident of Harrisburg, North Carolina, has seen her life shift as her vision deteriorates. Once running a nonprofit circus arts school, she had to close last year because she could no longer consistently handle the paperwork. She briefly tried pizza prep and now sorts recyclable materials at a local concert venue. That job is her main income, but it isn’t year-round.
“This place knows me, and this place loves me,” Kelley says of her employer. “I don’t have to explain to this place why I can’t read.” Living in a camper, she survives on less than $10,000 a year. Medicaid coverage has been a lifeline, paying for arthritis and anxiety medications and enabling regular doctor visits to manage high blood pressure.
Readers readers readers: support immigrant justice legislation; Jesse Jackson’s Portland visits marked moments of racial crisis; a poll rating Trump and other presidents. (These links illustrate the broader political context surrounding health policy debates.)
Yet Kelley’s worry is practical and immediate: next year’s rules will require millions like her to engage in at least 80 hours per month of work, volunteering, schooling, or other qualifying activities to gain or keep Medicaid coverage. “I’m scared right now,” she admits.
Before this policy shift was signed into law, some Republican lawmakers suggested that young, unemployed men were exploiting Medicaid. House Speaker Mike Johnson told CNN that Medicaid isn’t for “29-year-old males sitting on their couches playing video games.”
But the reality is different. Jennifer Tolbert of KFF explains that adults aged 50 to 64, especially women, are likely to be most affected by the new rules. For Kelley and others, the work requirements could create insurmountable barriers to maintaining coverage, potentially causing many to lose Medicaid and face heightened health and financial risks.
Starting next January, about 20 million low-income Americans across 42 states and the District of Columbia will need to demonstrate activity to obtain or retain Medicaid coverage. States that didn’t expand Medicaid under the Affordable Care Act (Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming) won’t implement these work rules.
The nonpartisan Congressional Budget Office estimates the rules will cause at least 5 million fewer people to have Medicaid over the next decade. Critics say the work requirements are a key mechanism in the broader GOP budget approach, which aims to cut nearly $1 trillion in costs, largely benefiting higher-income groups and increasing border security.
“Saving money at the expense of people’s lives” is how gerontology researcher Jane Tavares frames it, arguing the work requirement is a political tool more than a health policy fix.
The Department of Health and Human Services responds that requiring able-bodied adults to work is about Medicaid’s long-term sustainability and protecting the program for the truly vulnerable. Exemptions exist for people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship, according to HHS spokesperson Andrew Nixon.
Medicaid expansion has already provided a safety net for middle-aged adults who would otherwise be uninsured. Georgetown University researchers note that Medicaid now covers about one in five Americans aged 50 to 64, helping them access care before they become eligible for Medicare at 65.
Among women in the 50–64 bracket, keeping Medicaid can be even more challenging than for younger women, and their need for health services tends to be higher, Tolbert observes. Many in this age group are not meeting the required work hours because they serve as family caregivers or contend with illnesses that limit their ability to work.
Research from Tavares and colleagues shows that only about 8% of the total Medicaid population is considered “able-bodied” and not working. This group is largely very poor women who left the workforce to provide care, and among them, one in four are aged 50 or older. The researchers emphasize they are not indicative of healthy, active young adults.
There’s a risk that making coverage harder to keep could worsen people’s health and, paradoxically, undermine their ability to work by leaving chronic conditions untreated. Even if someone loses Medicaid, their ongoing health needs won’t vanish.
Many people begin experiencing health issues well before qualifying for Medicare. If they can’t address these issues affordably until age 65, they may end up sicker when Medicare kicks in, which experts say could raise costs for the program overall.
In this landscape, many in their 50s and early 60s aren’t in the traditional workforce because they’re caregivers for children or older relatives—a group some researchers describe as the “sandwich generation.” While the GOP framework allows some exemptions for caregivers, advocates warn those carve-outs are narrow and risk letting people slip through gaps.
Caregiver advocates like Nicole Jorwic of Caring Across Generations highlight the danger: sicker caregivers mean more families in crisis, as people forgo their own care and face mounting stress.
Paula Wallace, 63, from Chidester, Arkansas, embodies the tension. After decades of work, she now spends her days tending to her husband’s advanced cirrhosis. With new Medicaid work requirements on the horizon, she finds it difficult to imagine meeting them, especially since she would be away from home to work. Although her husband receives disability benefits and she should be exempt as a full-time caregiver, federal guidance on how exemptions are defined remains unclear. Arkansas and Georgia’s early experiences with Medicaid work programs show many enrollees struggle to navigate the system, raising concerns about who ends up protected and who doesn’t.
“I’m very concerned,” Wallace says, summing up a worry shared by many: the policy could push families into deeper hardship even as it aims to tighten eligibility and cut costs.
©2026 KFF Health News. Distributed by Tribune Content Agency, LC.
