Eight states are telling sick Medicaid patients they cannot wait until 2028 to prove they are too ill to work. Arkansas, Idaho, Indiana, Iowa, North Carolina, North Dakota, Ohio and Utah plan to impose Medicaid work rules stricter than what the federal government requires when the mandate takes effect in January 2027, rejecting a one-year cushion the Trump administration built into the new law for medically frail enrollees.
The federal One Big Beautiful Bill Act requires Medicaid enrollees to work, volunteer or study at least 80 hours a month, a mandate that applies to roughly 21 million people who gained Medicaid eligibility through the Affordable Care Act, according to Politico. To ease the transition, the Trump administration said states could let medically frail patients keep their coverage through 2027 without immediate verification, relying instead on self-attestation — a sworn statement, signed under penalty of perjury, that a person is too sick to work, without requiring a doctor's note. Self-attestation has long been accepted for Medicaid income reporting, but eight states have now rejected extending that same trust to medical frailty claims.
Conservative Groups Say Exemptions Aren't Strict Enough
The push to eliminate the grace period has been led in part by the Foundation for Government Accountability, which contracted lobbyists in Idaho, Indiana, Missouri, Montana, Nebraska, North Carolina and Utah. Jonathan Ingram, the group's vice president of policy and research, said his organization spent the past year encouraging lawmakers to require Medicaid recipients to prove they are too sick to work next year rather than simply attest to it. Some conservatives contend the Trump administration's Medicaid work requirements are not tough enough to begin with, and the Foundation for Government Accountability has recommended states reject the federal one-year grace period entirely. The group has received funding from the Koch family and other Republican megadonors, per the same report.
North Carolina offers one of the clearest examples of a state moving faster than Washington requires. Governor Josh Stein signed House Bill 696 into law in April, and the legislation explicitly bars state agencies from accepting self-attestation as the sole evidence for Medicaid eligibility or work-requirement exemptions, according to Carolina Journal. North Carolina's health department confirmed that the bill prohibits self-attestation as the only eligibility evidence, and state Senator Donny Lambeth said North Carolina is complying with federal law while addressing waste, fraud and abuse in health care.
Idaho And Others Move Even Faster
Idaho's governor signed a strict Medicaid work-requirement enforcement bill into law earlier this year after the state legislature passed it in spring 2026. Under Idaho's approach, new Medicaid patients can claim a medical-frailty exemption only during their first six months under the work rules; after that, the state requires proof of medical frailty at renewal and during eligibility checks that occur every six months. Idaho House Minority Leader Ilana Rubel warned that strict enforcement could cause tens of thousands more people to lose health insurance in the state.
Iowa's health department plans to use a single standardized verification process for Medicaid exemptions, while North Dakota's Medicaid agency has defended immediate verification by arguing that a consistent process creates a tracking record for future reviews. New Hampshire took a narrower approach, allowing only parents of young children and other limited categories to claim medical exemptions without state verification — though a court ruling has since blocked New Hampshire's work-requirement policy from taking effect before it could be implemented. An Urban Institute analysis had projected that more than 40 percent of New Hampshire Medicaid patients could lose coverage under that framework.
Lessons From Arkansas's Earlier Attempt
Arkansas has already lived through a version of this fight. When the state ran its own Medicaid work requirement starting in 2018, it granted exemptions to patients who simply said they were too sick to work, but roughly 29 percent of Arkansas Medicaid patients still lost coverage under that program. That earlier Arkansas policy was ultimately struck down in the 2020 case Gresham v. Azar, when the D.C. Circuit Court of Appeals ruled that federal approval of the work requirement was arbitrary and capricious because officials failed to consider how the reporting rules caused thousands of low-income patients to lose coverage, according to the North Carolina Health News account of the precedent. Whether similar legal challenges emerge as the new, stricter state rules take effect remains an open question.
Kinda Serafi, an attorney who studies Medicaid policy, said requiring provider documentation up front will burden medically frail applicants who may not have ready access to a doctor. Hilarie Matlock echoed that concern, noting that self-attestation is a sworn statement made under penalty of perjury and that uninsured sick people may be unable to obtain Medicaid coverage without first seeing a doctor they may not have. Ohio's Medicaid agency says it is working with federal health officials to find a solution for medically frail new enrollees who lack access to a physician, but in the meantime, Ohio state Senator Anita Somani said some patients in her state are already canceling surgeries and rationing medications rather than risk their coverage.
Democrats Warn Of A Widening Coverage Gap
Democrats have said the Trump administration's work requirements and its narrow medical exemption definition are too harsh even with the federal grace period in place, let alone without it. Nonpartisan analysts have projected that at least 5 million people will lose Medicaid over a decade under the federal work-requirement provisions, a figure that lines up with Congressional Budget Office estimates that the policy will cut federal spending by $326 billion over 10 years while increasing the uninsured population by 5.2 million to 5.3 million adults by 2034, according to the Georgetown University Center for Children and Families. A separate March 2026 Urban Institute study, cited by the Idaho Capital Sun, found that between 4.9 million and 10.1 million Medicaid expansion enrollees nationwide could lose coverage in 2028, with the size of that loss hinging directly on whether states choose flexible or restrictive verification policies like the ones now advancing in these eight states.
Nebraska became the first state in the country to actively enforce new Medicaid work requirements, starting May 1, ahead of the broader federal deadline of January 1, 2027, according to the Center for Health Care Strategies. States manage their Medicaid programs individually, even though the federal government pays the bulk of Medicaid expansion costs, and Medicaid spending growth is already running at more than double the rate of inflation nationwide. The federal government itself is not scheduled to require third-party verification of medical frailty until 2028, leaving 2027 as the year when the gap between federal flexibility and state strictness will be felt most directly by patients in Arkansas, Idaho, Indiana, Iowa, North Carolina, North Dakota, Ohio and Utah.
