For millions of Americans who rely on Medicaid for their health coverage, the second half of 2026 marks the beginning of the most significant eligibility change in the program's history. The One Big Beautiful Bill Act, signed into law on July 4, 2025, introduced work requirements that begin a phased implementation in December 2026, with full enforcement expected by 2027. The Congressional Budget Office estimates that 11.8 million people will lose Medicaid coverage directly as a result — and an additional 3.1 million will lose marketplace coverage as a downstream effect.
The requirement is straightforward on paper: most adult Medicaid enrollees between the ages of 19 and 64 must demonstrate 80 hours of monthly qualifying activity to maintain eligibility. Qualifying activity includes employment, job training, education, volunteering, or caregiving. The complication is in the documentation. Many people who already meet these thresholds — working part-time jobs, caring for children or elderly relatives, or enrolled in school — will lose coverage not because they fail to qualify, but because they fail to file the right paperwork at the right time with their state agency.
The populations at highest risk are not the unemployed. They are people with inconsistent work schedules, gig and seasonal workers whose hours fluctuate month to month, adults with informal caregiving responsibilities that are difficult to document, and people whose employers do not provide pay stubs or digital records. Research on earlier state-level work requirement experiments in Arkansas (before the courts blocked them) found that the majority of people who lost coverage were already working — they simply could not navigate the reporting requirements in time.
If your Medicaid coverage could be affected, the most important action to take right now is to update your contact information with your state Medicaid agency. States are required to mail notification letters before any disenrollment, but letters to outdated addresses mean coverage disappears without warning. Beyond that, begin collecting documentation of qualifying activity — pay stubs, school enrollment records, or a letter from a supervisor — before the reporting window opens in your state. Your state's Medicaid agency website will publish the specific timeline and documentation requirements for your situation.
If you do lose Medicaid coverage, losing this benefit triggers a Special Enrollment Period for ACA Marketplace plans. You have 60 days from the date your Medicaid coverage ends to enrol in a marketplace plan, and depending on your income, you may qualify for subsidies that significantly reduce the monthly premium. The 2026 ACA premium increases have made this more expensive than in prior years for many people, but at income levels previously covered by Medicaid, substantial subsidies are typically available.
The scale of potential disruption makes this one of the most consequential domestic policy changes for low-income Americans in a generation. Advocates and state agencies are both warning that administrative churn — losing coverage due to paperwork failures rather than genuine ineligibility — will likely account for the majority of disenrollments in the first year.