The One Big Beautiful Bill Act is now law. It makes sweeping changes to Medicaid that will affect millions of people over the next two years. Some will lose coverage. Others will face new work requirements. States are being asked to act fast, and the stakes are enormous.
If you or someone you know relies on Medicaid, you need to understand what's coming.
Work Requirements: 80 Hours a Month Starting January 2027
Starting January 1, 2027, Medicaid will require certain adults to work or participate in approved activities for at least 80 hours per month.
This applies to people aged 19 to 64 who are covered through the ACA Medicaid expansion or state 1115 waivers. Qualifying activities include:
- Employment (part-time or full-time)
- Job training and education programs
- Community service
- Other work programs approved by the state
The federal government can exempt states from this deadline if they show good faith effort, extending implementation until December 31, 2028. But most states will need to start verifying and enforcing these requirements by next January.
States will need systems in place to track who meets the requirement and who doesn't. That takes time, money, and coordination. Many states are still building these systems.
The Outreach Window: June 30 to August 31, 2026
Before work requirements kick in, states must tell people what's coming. Federal law now requires outreach between June 30 and August 31, 2026.
States must reach Medicaid members through multiple channels:
- Mail notifications
- Phone calls or text messages
- Website information
This is the window where Medicaid agencies will notify millions of people that they'll need to start tracking their work hours or risk losing coverage. If you have Medicaid through expansion and you're between 19 and 64, watch for these notices.
Coverage Losses If States End Expansion
The biggest financial hit comes if states decide to drop Medicaid expansion entirely. While federal law doesn't force states to eliminate expansion, the law removes financial incentives that made expansion attractive.
According to estimates from the Kaiser Family Foundation and the Urban Institute, if states eliminate their Medicaid expansions:
- 15.9 million people could lose Medicaid coverage
- 10.8 million of those people could become uninsured
This would be the largest loss of health coverage since the COVID-19 pandemic. States don't have to make this choice, but the financial pressure is real. States that expanded Medicaid because of the federal incentives are now facing a different calculation.
FMAP Changes: The Financial Incentive Disappears
When Medicaid expansion started under the ACA, the federal government paid 90 percent of costs for newly eligible adults. States paid the other 10 percent. This made expansion affordable.
The One Big Beautiful Bill changes this. As of January 1, 2026, states that newly adopt Medicaid expansion no longer get the temporary 5-percentage-point boost in federal funding. New expansion states will get the regular FMAP, which is much lower and varies by state.
This creates a perverse incentive: states that have not yet expanded Medicaid now have even less reason to do so. States that already expanded are now facing higher costs if they want to maintain coverage.
Emergency Medicaid for Immigrants: Lower Federal Match
Federal matching funds for emergency Medicaid services for immigrants are being cut. Effective October 1, 2026, the federal government will cover only the regular FMAP rate instead of the enhanced rate.
This affects immigrants who are not eligible for regular Medicaid but can access emergency services under federal law. States will now pay more out of pocket for emergency room visits, emergency surgeries, and other urgent care for this population.
It's a modest change compared to other provisions, but it will add pressure to state budgets and may discourage some states from even offering these services.
ACA Repayment: Low-Income Families Face Full Bills
During the pandemic, people who got ACA tax credits but earned too much were not required to repay the overpayment. That protection is gone.
Low-income enrollees who received subsidized health insurance through the ACA marketplace and got too many tax credits now face full repayment. This hits families that were already struggling financially.
The timing is harsh. Families will discover they owe money when they file taxes. For some, this could be thousands of dollars.
What Happens Next: A Critical Timeline
June 30 to August 31, 2026: States must send outreach notices to all Medicaid members about work requirements.
January 1, 2027: Work requirements take effect unless a state gets an exemption. People must start documenting 80 hours per month of qualifying activity or risk losing coverage.
December 31, 2028: The latest date states can delay work requirement implementation if they've shown good faith effort.
Between now and January 2027, states will be scrambling to build verification systems, train staff, and notify millions of people. The administrative burden is enormous. Some states will struggle. Others will move faster. Either way, the burden falls on individuals to prove they're working or participating in approved activities.
Who Is Most at Risk
Work requirements hit hardest on people who are already vulnerable:
- People with disabilities or chronic illnesses who can't work 80 hours a month
- Caregivers for children, elderly relatives, or people with disabilities
- People in rural areas with few job opportunities
- People with unstable housing or food insecurity
- People in areas with high unemployment
Federal law does allow some exemptions, but states have discretion over how broadly they apply them. A person who qualifies for an exemption in one state might not qualify in another.
The Coverage Crisis Ahead
States that expanded Medicaid during the ACA now face a choice: keep expansion going and pay higher costs, or scale back and eliminate coverage for millions.
Work requirements will cause additional coverage loss among people who can't meet the requirements, even with exemptions. Administrative errors—missed notices, failed documentation—will cause more people to lose coverage through no fault of their own.
All of this happens while health care costs are rising and uninsured rates are climbing.
Bottom Line
The One Big Beautiful Bill creates a two-pronged attack on Medicaid coverage. Work requirements starting in January 2027 will take away coverage from people who can't meet them. Removal of financial incentives will pressure states to scale back or end Medicaid expansion, potentially taking coverage away from 15.9 million more people.
If you have Medicaid through expansion, watch for outreach notices starting in June 2026. If you can't meet work requirements, look into available exemptions in your state. If you're uninsured and thinking about ACA coverage, be aware that tax credit repayment rules are now much stricter.
The next 18 months will determine whether millions of Americans keep their health coverage. Pay attention to what your state does.