The strict Medicaid work requirement at the center of the Republicans’ major policy bill wouldn’t just require millions of poor Americans to prove they are employed to sign up for health insurance. It would also require dozens of states to quickly build expensive and complex software systems to measure and track who is eligible.
This new responsibility for states, whose existing Medicaid computer systems are often outdated, would be accompanied by reduced federal funding through other changes in the bill. The result, according to state officials, software developers and policy experts, could be major failures in state systems for enrolling people in Medicaid.
“That’s how Healthcare.gov happens,” said Julie Brinn Siegel, a former top Biden administration budget official, referring to the Obama administration’s botched launch of the online Affordable Care Act enrollment portal in 2013.
Ms. Siegel and others familiar with Medicaid systems envision problems like websites that don’t load or incorrectly tell applicants they are not eligible. And Medicaid workers may be overwhelmed as they try to run call centers and process applications. The fallout could mean eligible Americans will have their coverage dropped.
Republicans contend that the work requirement achieves twin goals: It ensures that the government directs resources to Americans who are contributing to society, while saving money to help finance an extension of President Trump’s tax cuts.
Current and former state officials fear the issues could spill outside the population of working-age adults the work requirement is designed for, causing delays and errors for children, parents and Medicaid beneficiaries with disabilities.
“The worry is the consequences will fall really to the people who rely on the program, and they’ll lose health care coverage because we didn’t have enough time to have the systems ready and for us to do it right,” said Jay Ludlam, North Carolina’s Medicaid director.
Republicans are aiming to pass the bill before the July 4 holiday.
Dr. Mehmet Oz, the administrator of the Centers for Medicare and Medicaid Services, said states would be ready. “We are fully confident that technology already exists that could enable all parties involved to implement work and community engagement requirements,” he said in a statement. “C.M.S. will continue to engage closely with Congress, states and stakeholders to implement any future law.”
Former state Medicaid officials and experts on the topic are less certain that the systems could be built on the timeline the legislation envisions. Both the House and Senate versions of the legislation give states until the end of 2026. But the Senate bill would allow struggling states that are making a “good faith effort” a two-year extension. Forty-two states and the District of Columbia would need to comply — every state that expanded Medicaid under Obamacare, along with Wisconsin and Georgia, which cover some of the same population through waivers of the normal rules.
Before states could even start, they would need guidance from the Department of Health and Human Services on how states should enforce the work requirement. The Senate version of the bill gives the department until June 2026 to produce the guidance. States would probably be reluctant to build the technology to support a new application process until they knew the rules.
The legislation, for example, has an exemption for people who are too sick to perform at least one daily activity of living. It’s not clear how they would prove it.
“How do I verify that as part of an application process? Do I need them to see a doctor for an assessment, or can it be a self-attestation?” said Kevin Bagley, who previously ran the Medicaid programs in Nevada and Utah.
Then states would need to hire contractors to help them build technology systems to determine which people need to comply with a work requirement, who qualifies for a range of exceptions, and whether people subject to the requirement are, in fact, working. Some of the data that could make things run smoothly, like wage information, is held by private vendors that charge high prices for access.
Normally, government contracting takes months to write specifications and vet competitors. To save time, states would probably modify Medicaid technology contracts they already have and skip the bidding process, said a half-dozen current and former state officials. That would reduce their leverage to negotiate a good price.
“This is going to be a huge payday for government contractors,” said Luke Farrell, who worked for the United States Digital Service during the Biden administration helping states fix their Medicaid technology systems. “They get to build something once and then sell it 25 times.”
The handful of states that have already attempted work requirements in Medicaid spent tens of millions of dollars. Kentucky spent $250 million in 2018 on its program, before a court stopped it. But the Senate version of the bill allots only $200 million for the entire country.
States would also need to hire more workers to check time sheets, doctors’ notes and other documents as well as make application decisions. And they would need to staff call centers with employees who could answer questions from confused beneficiaries.
That may sap resources from other parts of Medicaid and could lead to more errors and longer waits for pregnant women and people with disabilities attempting to sign up. In eight states, more than a third of applications already take more than 45 days to process.
The two states that have actually put in work requirements show some of the hurdles that others could face.
When Arkansas started a work requirement in 2018, state officials worked hard to educate the public — mailing letters, sending emails, placing phone calls, briefing medical providers, posting on social media sites, distributing fliers. Still, around the time the program began, only about half of eligible people knew whether the work requirement applied to them. The website used to document work hours was not designed for smartphones and was routinely taken offline at night for maintenance.
Almost none of the people who were required to report work hours under the system did so in the first months of the program, and 17,000 people lost coverage before the program was stopped by a federal judge.
Georgia expanded Medicaid coverage in 2023 for low-income people who could prove they were working. But the state’s sign-up system is often glitchy. Documents that seem to upload sometimes don’t, or they are reviewed so late that a person trying to sign up has already missed a deadline, according to Cynthia Gibson, a managing attorney at the Georgia Legal Services Program, who has helped some Georgians appeal their denials. Only around 7,400 people have enrolled so far; the state expected around 100,000.
Adam Meier, who oversaw the Kentucky effort, estimates that the timeline in the congressional legislation is feasible.
He notes that states already have some data from other anti-poverty programs that have work requirements, which can help them determine eligibility. Outreach and technology, he said, would also be less of a challenge when most of the country is working on the same task concurrently.
The waiver process added in the Senate version of the bill could help some states flailing to build systems in time. But it will be up to the Trump administration to decide who has made a “good faith” effort.
Catie Edmondson contributed reporting.
Margot Sanger-Katz is a reporter covering health care policy and public health for the Upshot section of The Times.
Sarah Kliff is an investigative health care reporter for The Times.
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