On Jan. 1, as new work requirements go into effect for Medicaid beneficiaries, about 19 million Americans in 44 states are at risk of losing their federal health insurance, according to The New York Times. Yet in states with similar conditionalities, few people have actually failed to meet work requirements (usually called “community engagement requirements"). Medicaid is the nation’s largest health insurance program by enrollment and has been one of the most cost-efficient.

The most common causes of lost coverage are missed filing deadlines, confusing requirements, complex paperwork, and increased demands for documentation. However, the federal and state governments often already possess proof of employment because so many beneficiaries file income taxes. The workers at greatest risk of losing Medicaid coverage are part-time workers, seasonal workers, and gig workers like Uber drivers. These workers will need to provide old pay stubs, meet periodic deadlines, and complete recurrent forms. On Friday the Centers for Medicare and Medicaid Services announced that states may delay enforcement for six months.

In June 2018, Arkansas imposed work requirements, but 92% of those who lost their health insurance met all work requirements or should have been exempt, according to a study published in the New England Journal of Medicine. The Journal stated that the state’s program was “plagued by confusion,” and by March 2019 these Arkansas requirements were ended by a federal judge. Nebraska imposed work requirements in May 2026, but 90% of Medicaid denials were due to late or incomplete paperwork, according to the Times.