By Suzanne Wikle 

Access to health insurance and health care has never been a right in this country. There has always been a division between those that are considered “worthy” and those that are not, mostly along wealth and racial lines. The recent political conversations about Medicaid unfortunately reinforce this division.  

When policy makers debate eligibility criteria for Medicaid and other programs, they are really making a value statement about who deserves health care, food, or any other assistance. The new Medicaid rules, which will go into effect for the Medicaid expansion population in most states in 2027, make strong statements about who is worthy of Medicaid and who is not.  

The recent bill pushed by President Trump and passed by Republicans in Congress on razor-thin margins cuts over $800 billion from Medicaid—“saving” money by causing people to lose their health insurance. One of the primary ways the bill does this is by changing eligibility for Medicaid and attaching a “work requirement” for the 20 million people who are eligible for the Medicaid expansion program in their state. More than 10 million people are expected to lose their Medicaid insurance as a result of this Republican-led legislation.   

About half of people in the country have health insurance through their job, so it may seem like a natural step to attach Medicaid insurance to employment. Nothing could be further from the truth. This fundamental change in Medicaid eligibility undermines the intent of Medicaid and a large portion of the Affordable Care Act (ACA), puts lives at risk, and ultimately declares with more clarity than ever who is deemed worthy of health insurance and who is not. A core vision of the ACA was to provide a pathway to affordable health insurance outside of employment. This meant creating affordable options for people who owned small businesses, retired early, don’t have employer-provided insurance, or aren’t employed. 

Who is “Worthy”? 

In practice, the new Medicaid law draws arbitrary lines that determine eligibility. For example: 

If you’re a parent with a low income and a child under age 13, you are worthy of Medicaid for your health insurance. If you’re a parent with a low income and your child is 14 or older, you’re not worthy unless you’re working at least 80 hours a month. 

If you’re a waitress earning a low income and working at least 80 hours a month, you’re worthy. But if you get sick and need a few days off, you’ve worked less than 80 hours that month and are no longer worthy. 

If you work for a landscaping company and work at least 80 hours per month during the busy seasons, you’re worthy of Medicaid. But if there’s a particularly rainy month or cold snap and your hours are cut below the threshold set by Congress, you are no longer worthy.  

If you’re working in the gig economy to pay your bills and you are able to prove at least 80 hours of work per month, you are worthy and eligible. But if business slows down, your care is getting repaired for a few days, or you simply can’t produce the right documentation, you may not be worthy. 

If you’re able to navigate the complex paperwork requirements to prove your work hours, then you’re eligible. But if you can’t navigate the system or you don’t have adequate internet access to upload your documents, you’re not worthy enough. 

Racial Inequities in Health Insurance 

It’s not a coincidence that large racial inequities exist in health insurance rates. Systemic racism and states choosing not to expand Medicaid are two major reasons behind the disparities. In 2023, for adults ages 19-64 (the Medicaid expansion age range), white and Asian Americans had uninsurance rates of 7 percent and 6 percent, respectively. All other racial and ethnic groups had uninsurance rates at least double those: 23 percent for Hispanics, 12 percent for Black people, 21 percent for American Indian and Alaskan Natives, and 15 percent for Native Hawaiian/Pacific Islanders.  

Medicaid disenrollments due to work reporting requirements, like other administrative burdens, will exacerbate these inequities. People of color are disproportionately insured by Medicaid and will disproportionately be harmed by additional red tape.  

The ACA took many steps toward righting these wrongs and ensuring access to health insurance for everyone. It created a marketplace where people can get subsidies to purchase insurance that is required to cover essential health benefits. The ACA also expanded Medicaid to those with the lowest incomes—under 138 percent of the poverty line, or $36,777 per year for a family of three. 

Collectively, the three pillars of the ACA—employer-based insurance, marketplace insurance, and Medicaid—should have provided affordable health care to nearly everyone. When the Supreme Court ruled Medicaid expansion as a decision left to states, that core pillar of the ACA was cracked because it wouldn’t be part of the health insurance landscape in many states. Ten states are still refusing billions in federal dollars to expand their Medicaid program. 

The Current Landscape 

What Congressional Republicans and President Trump have done in 2025 is another significant blow to Medicaid. Tying eligibility for Medicaid expansion population to proving work hours will have one outcome: people will lose their health insurance. People won’t lose their insurance because they aren’t working; most people are working, or caring for someone else, or will meet another exemption. The evidence from other programs is crystal clear: this is a red tape and bureaucratic hurdle created to deter people from applying or making it too difficult to complete the application process. This is not about promoting work and will not increase employment. 

A Medicaid work reporting requirement also means that Medicaid will no longer be the safety net that someone can turn to when they lose their job. For those of us that receive health insurance through our employer, a job loss also means a loss of health insurance. For many in this position, keeping their insurance through COBRA is unaffordable. If they live in a Medicaid expansion state and their income drops below 138 percent of poverty, they have access to Medicaid.  

During the early months of the COVID-19 pandemic when millions of people lost their jobs, Medicaid was there for them. People who lost their jobs or were furloughed were 70 percent less likely to become uninsured if they lived in a Medicaid expansion state. Under the new eligibility rules mandating a work reporting requirement, people won’t have Medicaid to turn to when they are suddenly unemployed.  

These decisions have real-life consequences. People will lose their health insurance, which will cause them to forgo medical care and accrue medical debt; and some people will die. Millions of others will live far below the level of dignity they could have if they were guaranteed access to health care.  

Health insurance and health care access are policy decisions. CLASP strongly disagrees with the policy decisions of those who supported H.R. 1 and will continue to advocate for health care to be a basic human right for all.