The Trump administration moved last week to implement the most sweeping attack on Medicaid since the program’s founding in 1965, as states begin enforcement of the work requirements mandated by the so-called “One Big Beautiful Bill” (OBBB) signed into law by President Trump on July 4, 2025.

Medicaid is the health insurance program for the poor and disabled jointly administered by the federal government and the states. As of February 2026, there were an estimated 74.9 million people enrolled in Medicaid and the Children’s Health Insurance Program (CHIP), including approximately 39.2 million adults and 35.7 million children.

The work requirement policy compels adults enrolled in Medicaid through expansion of the program under the Affordable Care Act to document at least 80 hours per month of work, community service, education or job training programs—or lose their coverage. Verification must be submitted at least every six months, and states retain the option to demand monthly reporting. Those individuals who fail to comply face termination of coverage, often with little warning and through processes that have already proven, in earlier state-level experiments, to ensnare the working poor in mountains of paperwork they are ill-equipped to navigate.

The Centers for Medicare and Medicaid Services (CMS) estimates the amount an adult received in recent years in Medicaid expansion funds at $6,000–$6,500 annually. This means the benefit these recipients “earn” for their 80 hours a month, if they can prove their eligibility, works out to somewhere between $6.25 and $6.75 per hour—well below the federal minimum wage of $7.25, and a fraction of any state minimum wage where these people actually live.

Nebraska became the first state to impose the new federal rules on May 1, with Montana and Iowa scheduled to follow suit before the January 1, 2027 deadline by which all 43 affected states must comply.

The scale of the expected human damage is staggering. The Congressional Budget Office (CBO) estimates that the work requirement provisions will reduce federal Medicaid spending by $326 billion over 10 years—the single largest source of savings in the legislation—and strip coverage from an estimated 5.2 million adults by 2034. The Center on Budget and Policy Priorities projects a far wider impact, warning that between 9.9 million and 14.9 million people could be placed at risk of losing coverage once the full machinery of the law is in motion. The CBO further projects that the broader Medicaid provisions of the law will leave 7.5–7.8 million more Americans without health insurance by 2034.

“Sitting at home watching television”

The ideological scaffolding erected to justify this assault on working class healthcare is as brazen as it is contemptible. Dr. Mehmet Oz, the television pitchman turned administrator of the Centers for Medicare and Medicaid Services, has been the administration’s most vociferous mouthpiece for the campaign to stigmatize Medicaid recipients as moral failures and deadbeats undeserving of public support.

“If you’re sitting at home, which is true for the millions of people who are able-bodied on Medicaid, on average, you’re spending 6.1 hours watching television, or just hanging around,” Oz told interviewers. “So, as a path to prosperity, Congress very wisely said, ‘Let’s get you back into the workforce.’”

In a separate appearance on Fox Business, Oz went further, telling viewers that adults subject to the new requirements should “prove that you matter”—a formulation that lays bare the administration’s view of Medicaid recipients not as citizens with rights, but as supplicants who must earn the privilege of staying alive.

That 6.1-hour television figure, derived from an American Enterprise Institute study, refers to total leisure time across all socializing, relaxing and recreation activities—not, as Oz implied, hours spent inert in front of a screen. But the falsity of the claim is almost beside the point. The argument that the chronically ill, the intermittently employed, caregivers and the seasonally laid-off are simply too lazy to fill out the necessary paperwork every month serves the same political purpose it always has: to manufacture justification for the destruction of a program on which tens of millions of working people depend for their survival.

The Paragon Health Institute, the right-wing think tank that has served as intellectual vanguard for the administration’s Medicaid agenda, was equally forthright in a statement released this week on a new CMS interim final rule implementing the requirements. The rule, Paragon declared, “prioritizes work over welfare,” and “restores Medicaid to its original purpose: serving as a targeted safety net for the most vulnerable rather than an open-ended entitlement that discourages work and strains taxpayer resources.” Able-bodied adults, the group asserted, should “engage in employment, job training, education, volunteering, or community service—not rely indefinitely on welfare.”

Who will lose coverage?

The portrait of able-bodied idlers conjured up by Oz and his allies bears no relationship to the actual Medicaid expansion population. Studies conducted in Arkansas, which implemented work requirements briefly from 2018 to 2019, consistently found that the overwhelming majority of those who lost coverage were already working, were exempt from the requirements, or faced circumstances—disability, caregiving responsibilities, a seasonal layoff—that should have qualified them for exemption. They lost coverage not because they failed to work, but because they failed to successfully navigate a complex and unforgiving bureaucratic gauntlet.

Those at risk under the new federal rules span every corner of American life. (See: Who stands to lose: Faces of the Medicaid work requirement cuts)

Those whose coverage is jeopardized include the following hypothetical individuals. These composites are based on the documented demographic patterns of the Medicaid expansion population and the known mechanisms by which work requirements produce loss of coverage:

• A rural home health aide in West Virginia whose employer does not provide pay stubs and whose county has no stable internet access for online reporting.
• A gig worker in Atlanta who drives for a rideshare platform and whose income, fluctuating week to week, may fall below the threshold in any given month.
• A 58-year-old autoworker in Michigan laid off during a plant closure, scrambling to find new work while managing hypertension and pre-diabetes.
• A mother in Phoenix caring for two children while her husband works rotating shifts. She is ineligible for a childcare exemption because her youngest just turned 14.
• A cancer patient in rural Mississippi, still in treatment, whose oncologist’s paperwork confirming her medical exemption arrived one week late.

These are not exaggerated supposed cases. They are the predictable, documented consequences of imposing monthly documentation requirements on people whose lives are defined by economic precarity. The experience of Arkansas—where 18,000 people lost coverage in the first months of the program, the vast majority wrongly—has already established the template.

The administrative burden imposed by the new rules is itself a weapon. States must now build entirely new eligibility-verification systems, retrain workers, conduct outreach to millions of enrollees in multiple languages, and coordinate with labor agencies, educational institutions, and community organizations to verify compliance. The CBO estimates this will cost states $65 billion over 10 years. Georgia, whose earlier work-requirement waiver has already been in effect, spent approximately $9,000 in administrative costs per enrollee before its program was finally wound down.

State Medicaid agencies—already strained by the cumulative weight of federal funding cuts, more frequent eligibility redeterminations (every six months rather than annually), and restrictions on provider tax mechanisms on which states have relied to draw down federal matching funds—now face an implementation deadline that experts across the political spectrum have called unrealistic. A survey of state Medicaid officials published by Kaiser Family Foundation (KFF) and Georgetown University this spring found widespread concern about cost and timeline, and the absence of clear federal guidance from CMS.

Nebraska, which began enforcing requirements on May 1, has already seen early reports of eligible workers losing coverage due to paperwork failures, echoing the pattern first established in Arkansas.

Three promises, all broken

The scale of the social assault now underway can be grasped only against the backdrop of what Trump told the American people he would do.

In his very first campaign speech for the presidency in 2015, Trump declared he would “Save Medicare, Medicaid and Social Security without cuts.” On the 2016 campaign trail he boasted that he was “the only Republican” who would protect Medicaid, telling voters: “I’m not going to cut Social Security like every other Republican and I’m not going to cut Medicare or Medicaid.” As recently as May 4, 2025—while the OBBB was being assembled in Congress—Trump told NBC’s “Meet the Press” that he would veto any bill that cut Medicaid, insisting, “they’re not cutting it.”

The bill he signed last July cuts Medicaid by a staggering $793 billion over 10 years.

Trump made a second promise, equally explicit. In January 2017, just days before his first inauguration, he told Axios: “There will be nobody dying on the streets in a Trump administration.” He had made a version of the same pledge at a Republican primary debate in February 2016, declaring: “We’re going to take care of people that are dying on the street because there will be a group of people that are not going to be able to even think in terms of private [insurance coverage] or anything else.”

Those words now ring as a bitter indictment. The people who will be stripped of Medicaid under Trump’s bill are precisely the people he claimed to be protecting—workers without employer-sponsored insurance, the chronically ill, caregivers, the seasonally unemployed. They will die as people without health coverage always die: incrementally, from conditions caught too late, from medications they could not afford to refill, from emergencies that went untreated until there was nothing left to treat. The street, in Trump’s formulation, was a metaphor. The dying is real.

Trump also spoke, in the days surrounding his first inauguration, of providing “insurance for everybody”—a phrase that briefly led commentators to wonder whether he was gesturing toward universal coverage. “We want people taken care of,” he told Axios. He subsequently retreated from the formulation, but the sentiment—that his administration would ensure no American was left without care—was central to seeking support among working class voters who had been left unprotected by the existing system.

The reality: The OBBB does not provide insurance for everybody. It removes insurance from millions. It does not protect Medicaid. It guts it. And the people it leaves to face illness without coverage will not be, as Trump’s mythology insisted, the lazy or the fraudulent. They will be the home health aide, the rideshare driver, the laid-off autoworker, the cancer patient waiting on paperwork.

Class war and the consolidation of personal rule

The Medicaid assault is not an isolated policy dispute. It is a component of the Trump administration’s systematic dismantling of every institution and program that even modestly mediates the relationship between capital and labor in favor of working people. It unfolds alongside the gutting of the National Labor Relations Board, the attack on the Social Security Administration, mass deportations intended to drive down wages and terrorize immigrant workers and their families, and the consolidation of executive dictatorial authority.

The working class will overwhelmingly recognize the Medicaid work requirements for what they are: not a policy adjustment, but a weapon in a class war being waged from above by an administration that increasingly governs through executive decree, the intimidation of political opponents, and the systematic looting of public resources accumulated through decades of working class struggle. The defense of Medicaid—like the defense of Medicare, Social Security, public education and every other social gain of the 20th century—requires not appeals to Democratic Party politicians who collaborate in the conditions that make this assault possible, but the independent political mobilization of the working class in its own interests based on a socialist program.