Work Requirements and Medicaid Enrollments: Will States Stanch Erosion?

Abstract The enactment of the One Big Beautiful Bill Act in July 2025 has introduced rigorous Medicaid work requirements, sparking projections of significant coverage losses for millions of low-income Americans. This essay examines the administrative and political dynamics that will determine whether states can mitigate this enrollment erosion. The Congressional Budget Office estimates that eligibility provisions, particularly work mandates for the Affordable Care Act's expansion population, will account for the majority of projected federal savings. We identify five primary coping strategies states may use to stanch declines, including expanding ex parte (automatic) determinations, limiting look-back periods for work history, and aggressively documenting “medically frail” exemptions. Implementation is expected to follow a pattern of partisan federalism, where Democratic-led states prioritize take-up practices to maintain coverage, while Republican jurisdictions may adopt policies—such as frequent eligibility reviews and monthly premiums—that exacerbate declines. Ultimately, the Trump administration's approach to federal compliance, financial support for systems development, and approval of restrictive waivers will be pivotal in shaping the law's long-term impact on the Medicaid safety net.