Federal regulators should act urgently to prevent millions of people with low incomes from losing Medicaid coverage under new work requirements, Human Rights Watch and Oxfam America said in a joint letter to the US Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) last week.The agencies face a June 1 deadline to issue guidance to states on how to implement these new rules, which risk undermining the right to health and worsening inequality, according to new research conducted by Human Rights Watch and Oxfam America.
The 2025 One Big Beautiful Bill Act (OBBBA) will require most adults with low incomes and without dependents to document at least 80 hours per month of work, education, or related activities by the end of 2026 to maintain Medicaid coverage in the 40 states and the District of Columbia that expanded Medicaid coverage under the Affordable Care Act. The Urban Institute estimates that between 4.9 and 10.1 million people could lose Medicaid coverage by 2028 because of these new requirements.
"These work requirements address a problem that doesn't exist since most Medicaid recipients are already working," said Matt McConnell, economic justice and rights researcher at Human Rights Watch. "They won't fix the budget. They just strip health care from millions of low-income people by making it harder for them to prove they qualify."
Human Rights Watch and Oxfam America's letter draws on a joint research in Georgia, which in 2023 expanded Medicaid coverage to adults without dependents but conditioned eligibility on meeting work requirements similar to those in the OBBBA. Available data and interviews with health care providers, policy experts, and people with experience navigating these work requirements show that poorly administered enrollment and verification systems, rigid reporting rules, and technical failures frequently cause eligible people to lose or be denied Medicaid coverage.
A 36-year-old woman in Atlanta had been working as a supermarket cashier receiving healthcare coverage through Medicaid, meeting work requirements, until the birth of her child in late 2025. "After I had the baby, my Medicaid and food stamps were turned off," she said. "[They] said that I failed to report that I was working." She has spent months trying to restore coverage while accumulating medical debt and struggling to afford food and rent. "It's hectic," she said. "You're not able to reach anybody."
The organizations also documented similar failures under the Supplemental Nutrition Assistance Program (SNAP), which provides food assistance and is also subject to expanded work requirements under the bill.
Medicaid is a means-tested public health insurance program for people with low or no incomes. It provides healthcare coverage for more than 68 million people in the US, including nearly 20 million adults covered through the Affordable Care Act's expansion, who will be subject to these work requirements. The program is jointly funded by federal and state governments but is administered by the states under federal law, with HHS and CMS responsible for issuing and overseeing compliance with national regulations.
The OBBBA, which became law in July 2025, extended and deepened expensive tax cuts that overwhelmingly benefit the ultra-wealthy. The nonpartisan Congressional Joint Committee on Taxation found will that the top 0.1% of earners will receive an average tax cut of $311,000 in 2027, while the lowest-income households will see their taxes increase. It also radically reduced federal spending on public services and programs, including through more restrictive eligibility and reporting requirements. The Congressional Budget Office, a nonpartisan government research agency, found that these changes will reduce after-tax and transfer incomes for the bottom 20 percent of US households while benefiting the richest households the most.
According to KFF, a nonpartisan health policy research organization, more than 6 out of every 10 people on Medicaid are already working full or part time. About 3 out of 10 aren't working because of caregiving responsibilities, disability or illness, or because they are attending school. Fewer than 1 in 10 are unemployed for another reason, but most of them are over age 65.
The large share of working adults on Medicaid reflects flaws in the US' employer-based health insurance system. Many low-paying employers avoid providing health insurance to employees by considering them consultants or part-time workers.
"Work requirements are sold as sensible, pragmatic reforms, but the lived reality couldn't be more different," said Jackson Gandour, senior policy advisor for economic justice at Oxfam America. "In practice, evidence shows they can create unfair and effectively insurmountable barriers for people who need coverage and are making every effort to meet the requirements."
Work requirements compound existing barriers to accessing public services and social protection programs that disproportionately affect people with low incomes, those in rural areas, people with disabilities, and people experiencing homelessness. Unreliable internet and phone access, unstable housing, limited in-person assistance, and error-prone online enrollment systems all contribute to the denial and disenrollment of eligible people.
At the same time, work requirements divert public funds away from care. The Georgia Budget & Policy Institute found that fewer than one out of every three dollars spent on the Georgia program during its first two years went to healthcare services, while nearly half went to error-prone administrative and technology systems needed to enforce eligibility.
"If you don't understand something, or you're trying to understand what they need, you can't get a hold of anyone to ask," said a 48-year-old woman in Atlanta, who said that her SNAP benefits were terminated for missing documentation, despite submitting verification of her hours volunteering in the community through the state's online portal. Though she is eligible for Medicaid, she pays out of pocket for private insurance to avoid the headache, even though her premiums recently doubled. "What they fail to realize is that a lot of people working still need assistance," she said.
Human Rights Watch and Oxfam America urged federal authorities to issue guidance for states that will help prevent work requirements from causing harmful and unnecessary Medicaid denials and terminations. This includes reducing documentation requirements, broadly interpreting exemptions, and recognizing a wide range of qualifying activities that reflect real labor conditions, including gig work, unpaid caregiving, and seasonal employment.
Under international human rights law, everyone has the right to the highest attainable standard of physical and mental health. Means-testing access to public health insurance already contributes to the more than 26 million uninsured people in the United States, who may incur potentially devastating medical costs and must often forgo or ration care. Further conditioning coverage though complex work reporting requirements is likely to exclude millions more, undermining their rights to health, food, and social security, while deepening inequality.
"Much of the harm these work requirements will cause is predictable, but also preventable," McConnell said. "Federal regulators should ensure that states implement these rules in a way that protects people's rights, rather than stripping them of health care through bureaucratic barriers."
