Coverage Losses Are Not a Hypothetical: What We Learned from Arkansas and What National Modeling Predicts

This article is part of our ongoing series on Medicaid Eligibility Series where we’re exploring the far-reaching implications of the One Big Beautiful Bill Act (H.R.1).

Coverage Losses Are a Feature, Not a Flaw

Historical evidence and federal modeling make one thing clear: tying Medicaid eligibility to work requirements will lead to substantial coverage losses. But it’s not because people don’t want to work. Instead, the primary drivers are administrative hurdles, reporting complexity, volatile work hours, and life circumstances that make perfect monthly compliance difficult. The risks are real, and they’re measurable.

Arkansas: A Real-World Warning

In 2018, Arkansas became the nation’s first test case for Medicaid work requirements for expansion adults. The results were swift and severe:

• Over 18,000 people (about 25% of those subject to the mandate) lost Medicaid coverage in just a few months.
• Research confirms these losses were administrative, not behavioral. Most disenrolled individuals were either working or exempt, but failed to navigate the new reporting rules.
• Confusion was widespread. Many enrollees did not understand the new requirements despite outreach efforts, and the state’s online-only reporting system created additional barriers for those without reliable internet access or digital literacy.
• The policy had zero impact on employment rates among the target population. The only measurable outcome was an increase in the uninsured rate.

Arkansas demonstrated that work requirements function less as labor policy and more as a coverage-reduction mechanism primarily through procedural disenrollment.

National Modeling: Millions at Risk

On a national scale, the projections are even more striking.

Congressional Budget Office (CBO) Projections

• Approximately 18 million people would be subject to work rules each year.
• An estimated 1.5 million would lose Medicaid annually once the policy is fully implemented.
• Over ten years, the work requirement alone would lead to roughly 5 million fewer Medicaid enrollees, part of even larger reductions within the broader law.

Urban Institute Estimates

A separate analysis projects 5.5–6.3 million Medicaid expansion adults would lose coverage if work requirements are implemented nationwide.

These represent some of the largest coverage losses in modern U.S. history.

When Coverage Is Lost, There’s Nowhere Else to Go

A crucial, and often overlooked, detail in H.R.1:
Individuals disenrolled from Medicaid for failing work requirements are barred from receiving ACA marketplace subsidies (provided those subsidies are available).

This closes the only realistic alternative coverage pathway for low-income adults.

That means:

• Disenrolled individuals face full, unsubsidized premiums on the private market.
• For most, those costs are entirely out of reach.
• The overwhelming majority will become uninsured.

Modeling from the Commonwealth Fund estimates that of the 5.5+ million losing Medicaid, 5.1–5.8 million will end up uninsured, only a very small share will secure other coverage, such as employer-sponsored plans.

Who Will Be Hit the Hardest?

Certain groups are at disproportionately high risk:

• Childless adults in their 30s–50s (mirroring patterns seen in Arkansas)
• Low-income workers in jobs with variable hours, who can easily fall below the 80-hour threshold in a given month
• Individuals with unstable schedules, caregiving responsibilities, or intermittent illness
• Workers who lack consistent internet access or the digital skills needed to meet reporting requirements

For these populations, a single missed report can mean losing coverage, not because they aren’t working but because the system is unforgiving.

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Note: This article was written when ACA premium subsidies are slated to terminate (at the end of 2025), yet are still under congressional debate to remain.