Trump’s new Medicaid rules will kick in, and GOP states are tougher. Someone may be too frail to work but can’t afford to see a doctor to prove it

Starting in January, certain Medicaid beneficiaries across the United States will face new work requirements due to President Donald Trump's 2025 tax cut and policy law, with some Republican-led states taking a more stringent approach than mandated. The crux of the issue lies in proving medical frailty, which prevents someone from working.

While federal regulations allow states to rely on the beneficiary's self-attestation for the first year, six states and more are likely to follow suit. This could pose challenges, particularly for new applicants who cannot afford medical consultations. Jennifer Tolbert, director of state health policy and data at KFF, explains that those unable to work might not be able to see a doctor due to financial constraints, leading them to apply for Medicaid, only to be asked for provider documentation.

A handful of Republican-led states are imposing stricter rules than required, and 25 Democratic-led states are challenging the new regulations in court, arguing they are too harsh. Some advocate for documentary evidence to prevent fraud, while the conservative Foundation for Government Accountability encourages states not to make the work requirements too lenient, believing able-bodied adults are driving up enrollment and costs.

States like Arkansas, Idaho, Indiana, New Hampshire, North Carolina, and Ohio have laws barring self-attestation, while Missouri Republican Rep. Darin Chappell is pushing for a constitutional amendment requiring documentary evidence for work exemptions. The new mandate applies to 20 million lower-income adults without children in 40 states and the District of Columbia, requiring them to work or volunteer 80 hours monthly or be in school at least half-time, with exceptions for medical frailty.

The Centers for Medicare and Medicaid Services recently published stricter guidelines, requiring a condition to significantly impair the ability to work, volunteer, or attend school. Currently, states decide annually whether recipients remain eligible, but the new law will require bi-annual assessments starting in 2028, with self-attestation only allowed once per enrollment.

States are expected to rely more on third-party data, such as workers' compensation claims and prescription information, to make determinations, though many will first need to upgrade their computer systems. Some states, such as Arizona, have already faced difficulties implementing new requirements, leading to significant enrollment declines.

Patient advocates warn that the added paperwork and hoops may deny aid to those genuinely unable to work, emphasizing that diagnostic services are widely available.