Medicaid work rule leaves homeless people in the cold

07 Aug 2026, 13:20 · Medical Xpress

by Katheryn Houghton

edited by Sadie Harley, reviewed by Alexander Pol

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In the spring, the federal government finalized regulations requiring millions of people who receive Medicaid benefits to prove they're working, volunteering or going to school to keep their coverage.

States have until January to begin those checks. Montana, Arkansas and Nebraska have already started implementing them.

The Trump administration's federal work requirements exempt certain groups of people: those with disabilities, those older than 64, pregnant people and Native Americans, among others. To receive an exemption, anyone without a clear-cut qualification—such as through their age or disability status—will have to prove they're too sick to work.

But the administration decided that being homeless isn't a medical condition and can't count as an automatic exemption from having to meet the new requirements. Many conservative policymakers support work requirements, and some states have attempted to implement such rules for years. At least four states—Montana, Arizona, Kentucky and Utah—previously proposed policies that included homelessness as an exemption.

But federal officials have said that's not allowed. In an email to KFF Health News, the Centers for Medicare & Medicaid Services declined to provide a comment on the record. But the agency confirmed that states must stick to the federal government's list of exemptions.

Homelessness in the U.S. increased by 27% from 2013–2025, according to data from the Department of Housing and Urban Development. Last year, about 746,000 people were homeless.

Many qualified for Medicaid, though the number of enrollees who are homeless is difficult to measure. In 2023, 55% of patients who received medical or behavioral health services through one of the nation's roughly 300 Health Care for the Homeless programs were enrolled in Medicaid.

Jennifer Tolbert, deputy director of KFF's Program on Medicaid and the Uninsured, said the federal regulations are a lot stricter than many states had expected, even those on board with work requirements. (KFF is a health information nonprofit that includes KFF Health News.)

"It took everyone by surprise," Tolbert said.

Dr. Mehmet Oz, who leads CMS, touted the regulations as a "path to prosperity" during a news conference in June.

"We need to get people to try to work," Oz said.

In June, 25 mostly Democratic-led states sued the Trump administration over the regulations, arguing the medical frailty standard would be too hard for enrollees to meet—and for states to assess. The work requirements are projected to increase the number of uninsured people nationwide by more than 5 million by 2034, according to the Congressional Budget Office.

Most states will begin to implement the Medicaid work requirements in January.

Montana plans to begin booting Medicaid enrollees from coverage this October if they can't prove they're in compliance with the work requirement

The differences between the states' and federal government's exemption lists don't end with people who are homeless. In Montana, lawmakers also planned to excuse people fleeing domestic violence and caregivers of hospitalized family members—two other groups left off the federal exemption list.

"These are simply parties that, due to a number of conditions, cannot meet those requirements," Republican state Rep. Ed Buttrey said in 2019 when the Montana Legislature passed its first Medicaid work requirement bill. Buttrey did not comment for this article.

Federal officials have said many people who are homeless could fall under another exemption, such as being too sick to work. But, like many states, Montana's system to automatically conduct those checks through existing medical records isn't ready, though health department spokesperson Jon Ebelt said it should be in place by October. Anyone not automatically exempted by the state would have 30 days to prove their case.

A possible exemption for health

Cassidy Kipp, who heads Samaritan House, said once people find shelter and start to stabilize, they typically find work. But even then, meeting the new requirements can be challenging. Clients often start with temporary and informal jobs—such as cleaning out a storage unit—that don't come with a pay stub, Kipp said.

Kaitlyn Bosshardt, a social worker at Partnership Health Center, a health clinic in Missoula, has seen more people priced out of longtime rentals as housing costs outpace people's paychecks. Meanwhile, affordable housing and rental aid are limited.

Partnership Health is one of roughly 1,400 health centers nationwide that receive federal funding to serve patients based on what they can afford—meaning even those who lose Medicaid can receive care. But organizations representing health centers have said if too many patients lose the coverage, some clinics won't be able to fill the financial hole.

The other problem is that these clinics generally don't provide specialty care.

Key medical concepts

Homeless Who's behind this story?

Sadie Harley

BSc Life Sciences & Ecology. Microbiology lab background with pharmaceutical news experience in oil, gas, and renewable industries. Full profile →

Alexander Pol

PhD nano-engineering from Delft University. Published researcher and journal reviewer. Brings scientific insight to content standards. Full profile →

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