One More Worry For College Students: Medicaid Work Requirements

“The uncertainty is really scary,” says Garth Bittner, a 28-year-old studying aerospace engineering at College of the Canyons, a community college in Santa Clarita, California. So scary, that he actually read through parts of the 800-plus-page tax and budget bill President Trump signed into law on July 4th.

Surprisingly, Bittner wasn’t looking for answers about the new law’s $307 billion in cuts to the student loan program over the next decade, which (among other things), will make repaying loans on income-based payment plans more burdensome. Instead, he was focused on the law’s $911 billion in Medicaid cuts, specifically a new “work requirement” slated to take effect at the start of 2027 and projected to save $326 billion over the next decade, largely by kicking people off the program.

Millions of undergraduate and graduate students now rely on Medicaid for health coverage. Students who attend school more than half time, should, in theory, meet the new work requirement. But yet-to-be issued rules and procedures, along with paperwork problems and administrative snafus, could put many of them at risk.

The new work requirement is contained in what Republicans have dubbed the One Big Beautiful Bill Act (OBBBA) and applies to the more than 20 million adults who receive coverage as part of the Medicaid expansion that was part of the 2010 Affordable Care Act (popularly known as Obamacare). The Supreme Court ruled the expansion was voluntary for the states, which administer Medicaid. Nevertheless, 40 states and the District of Columbia have adopted Medicaid expansion, which allows adults with income up to 138% of the poverty line ($21,597 for a single individual in 2025) to qualify for Medicaid.

According to a recent report from Congress’ Government Accountability Office, between 2010 and 2022, the share of undergraduate and graduate students who were uninsured shrank from 19% to 9%. Some of those coverage gains came from a provision in ACA that allows young adults without their own health coverage to stay on their parents’ employer-provided health insurance until they are 26.

But even more came from Medicaid expansion. In 2022, the GAO found, 13% of all college students, up from 7% in 2010, were covered by Medicaid. Equally telling, according to the GAO, 12% of college students in states that didn’t expand Medicaid lacked coverage in 2022, twice as high as the percentage who went uninsured in the expansion states. (Some colleges offer their own health plan and require all students to be insured, while others don’t.)

Under the newly-passed work regime, technically called “community engagement compliance,” Americans aged 19 through 64 will have to prove at least twice a year that they’re working, volunteering or in a work training program for at least 80 hours a month, or enrolled in an educational program at least half-time. Those who are caring for a child below 14 or have a medical condition that makes work impossible can qualify for an exception.

Republicans tout the new requirement as a way to get able-bodied people to join the workforce and ultimately become self-sufficient. But Democrats and many health policy experts warn that millions of otherwise eligible recipients (including those who are working or going to school) will lose coverage because of bureaucratic gotchas.

“The bottom line of what everyone expects is there’s going to be massive paperwork and massive confusion,” says Leighton Ku, the director of the Center for Health Policy Research at George Washington University.

The OBBA provides that students who can prove they’re enrolled in a higher education program at least half-time will meet the community engagement requirement. But it doesn’t define what constitutes half-time enrollment. In fact, that’s just one of many issues specific to college students that will need to be clarified by either federal regulations, or in federal guidance to the states (which they then would interpret), before the work requirement takes effect at the start of 2027.

Besides the short time frame, experts see another problem: States may not have (or be ready to spend) the money needed to set up efficient verification systems that don’t cut eligible people off. The new law provides just $200 million in federal funds to help states build the infrastructure for tracking Medicaid work requirements in fiscal year 2026. But they’ll likely need to spend a lot more to develop adequate systems. For example, Georgia, which implemented a Medicaid work requirement in July 2023, has spent nearly $100 million setting up the program, including an estimated $55 million to develop a digital system for verifying eligibility.

Andrea Ducas, the Center for American Progress’ vice president of health policy, ticks off a series of still unanswered questions that will affect college students on Medicaid. “What constitutes half-time enrollment? Does that enrollment also extend to times that you’re not in the school, like if you’re on a summer break, or if you’re a student that isn’t continuously enrolled in a program, but goes during different semesters.”

It’s still unclear, she notes, what will happen to students who are enrolled in an educational program when they apply or submit paperwork to requalify for Medicaid, but weren’t enrolled the month before. That’s because the legislation states that when eligibility is redetermined every six months (or more frequently if states choose), states are required to “look back” for at least one month to determine if the applicant met the work requirement or qualified for an exemption in the previous month. Just as they can choose to redetermine eligibility more than twice a year, states can choose to look back for multiple consecutive months. Those lookbacks could hurt college students whose schedules change over the course of the year, worries Carolyn Fast, The Century Foundation’s director of higher education policy.

“You could see a situation where a student who wasn’t enrolled [in school] over the summer or wasn’t enrolled for one semester is going to have trouble either getting enrolled [in Medicaid] or staying enrolled,” she says.

Bittner takes a full course load at College of the Canyons. But he shares the experts’ concerns about getting caught by the frequent recertifications and look backs. “Do you have to time it so that you’re enrolling (in Medicaid) when you’re in school and potentially going summer without health insurance? Nobody knows,” he says. “You’re going to have to submit more paperwork to show that you go to school more often and if anything goes wrong, and things always go wrong with these programs, you could lose it and then it takes forever to get somebody to correct it.”

As a resident of California, Bittner might have less to worry about than students in some other states. GW’s Ku says a lot could depend on how states chose to implement the verification process, including the frequency of checks, number of months they look back and types of data used. “They could say ‘Gee, for July and August you weren’t in school half-time, so therefore you didn’t meet the requirement,” he observes. But a state could also opt to check only twice a year with a one-month look back or accept a student’s two-semester course schedule as adequate, despite the summer break.

Adrianna McIntyre, an assistant professor of health policy and politics at Harvard University, offers additional unknowns: What types of educational programs will count towards the requirement? And how difficult will it be for those who work part time and attend school part time to meet the 80 hour requirement?

The legislation permits people to combine qualifying activities to reach the requirement, but she fears some students who are enrolled in one or two classes and work part-time could struggle to compile the necessary paperwork to prove their eligibility every six months. “These requirements create more homework for students. The government is giving them homework on top of their schoolwork,’’ McIntryre observes. “A lot of people just aren’t going to successfully navigate that.”

Allie Gardner, a senior policy analyst on the Center on Budget and Policy Priorities’ health policy team, points to another requirement that could trip up students on Medicaid. In addition to proving they meet the work/school requirement at least twice a year, Medicaid expansion recipients will also need to prove at least twice a year (up from once a year) that their income still qualifies them for Medicaid with separate documents. So even if states set up systems that automatically verify education status, they may not automatically verify students’ income.

“Basically everyone, including college students, may be hit with this double paperwork burden of having to prove compliance with the work requirement while also completing a full redetermination of eligibility,” Gardner says. (This more frequent income recertification is expected to save another $63 billion, on top of the savings from the work requirement.)

Some states already have online portals for Medicaid enrollment, but Gardner says some folks seeking coverage report difficulties using these websites and opt for mail. That presents yet another gotcha for college students: They could miss notices if they use their home address while at school, but also risk losing coverage from their home state if their school address is out of state.

“Let’s say because they want to make sure they get their mail for their renewal to meet the paperwork burden, [a student] submits their college address in another state. That could trigger the state thinking that someone is now enrolled in a Medicaid program out of state and they could lose Medicaid coverage,” Gardner says.

That means, she adds, that it will be crucial for states and universities to communicate state-specific policies, but they can’t even formulate these policies until they get federal guidance. That “makes the timeline to implement work requirements in the next year and a half very difficult,” she adds.

The correlation between heightened paperwork and qualified people never getting –or losing– Medicaid coverage is strong, as demonstrated in Georgia, the only state that currently has a work requirement through its Pathways to Coverage program (which it adopted instead of a standard ACA expansion for poor, able-bodied adults). As of May, only about 7,500 of the nearly 250,000 theoretically eligible people in Georgia were enrolled, with critics largely attributing low enrollment numbers to heightened paperwork.

“I think that the overall story of Georgia is proof of how somebody could leave home, go to college, not be able to afford the student insurance, and not be able to get Medicaid coverage they are otherwise eligible for because of all of the paperwork burdens,” Gardner says.

Leah Chan, Georgia Budget and Policy Institute’s director of health justice, says students in Georgia have a comparatively easier time than others when it comes to the new systems. That’s because if they submit an official course enrollment schedule at the start of a semester, it exempts them from reporting hours monthly. Plus, as students, they likely have an easier time navigating an online system than older or less educated folks.

But students aren’t immune from problems. In June, the Georgia group spotlighted the case of a graduate student and former social worker who lost coverage after having problems with the website and then struggling to get help through to the state call center. “There’s glitchy technology, there’s overburdened caseworkers who aren’t able to answer your questions,” Chan says. “So people are still falling through the cracks because of the added paperwork and the bureaucratic red tape.”

Chan says states will need to establish not only tech systems for tracking eligibility, but also high quality phone-based and in-person support for Medicaid users and outreach programs to make sure people know what forms they need to submit.

“People call them startup costs, but really what we’re seeing is that making modifications to the eligibility enrollment system is an ongoing cost, and so that is something that I think states are going to need to be mindful of,” Chan says.