In states that have long refused to expand Medicaid to more low-income adults, people in the program aren’t subject to new rules under the One Big Beautiful Bill Act requiring them to prove they’re working in order to get and keep coverage.
That’s not stopping Florida lawmakers from trying to adopt Medicaid work requirements anyway. It’s the only legislative body in a nonexpansion state to even consider it so far.
“You need to go to work if you want your friends and neighbors to pay for your health care,” said state Sen. Don Gaetz, the Republican sponsor of a Medicaid work requirement proposal making its way through the legislature.
The move baffles health care advocates and Medicaid experts. Some doubt it’s even legal under President Donald Trump’s signature domestic policy law.
“You cannot change the terms of the work requirement,” said Leo Cuello, an attorney and a professor at Georgetown University’s McCourt School of Public Policy, citing guidance issued by the Centers for Medicare & Medicaid Services. For Cuello, the answer is clear: “It’s a pretty easy no.”
Medicaid work requirements affect Washington, D.C., and the 40 states that have expanded Medicaid eligibility to all nondisabled adults ages 19 through 64 with incomes up to 138% of the federal poverty level, as prescribed under the Affordable Care Act. That’s an income of $22,025 a year for a single person.
Starting next January, those states must require people in their expansion groups to report at least 80 hours a month of work, education, or community service to qualify for and maintain Medicaid coverage.
About 4 million people are enrolled in Florida’s program, and Gaetz estimates that about 147,000 of them are adults who “could work and should work.”
They “are able-bodied and they don’t have small children at home, and they aren’t taking care of an elderly person or a disabled person,” he said. “Yet they receive Medicaid benefits.”
People affected by the Senate bill would primarily be parents of children 14 and older, and some 19- and 20-year-olds, he said. A companion bill in the Florida House would apply Medicaid work requirements to parents of children ages 6 and older.
To qualify for Medicaid in Florida, a working-age adult without a disability must generally be caring for a child or an older or disabled family member and cannot earn more than 26% of the federal poverty level, or about $592 a month for a family of three.
Most adults who are not disabled and receive Medicaid already work, and many people in low-paying jobs do not receive health insurance through an employer, according to KFF, a health information nonprofit that includes KFF Health News. Among single adults ages 19 to 64 in Florida who made under $15,000 a year in 2024, about 17% had health insurance through work.
Critics say Florida’s proposal would likely force some people to become uninsured, even if they meet the work requirement. That’s because the state’s Medicaid income limit is so low that working the mandated 80 hours a month would likely cause those individuals to exceed the income eligibility limit but also leave them earning too little to qualify for subsidized coverage on the Affordable Care Act marketplace.
Michelle Mastrototaro said she lost her Medicaid coverage in November after taking a part-time job as a teaching assistant at a Tampa elementary school last year. Mastrototaro, 47, cares for a disabled teenage son and likely would not need to meet Florida’s proposed work requirement.
But she said her biweekly wages from working about 17 hours a week pushed her past the Medicaid income limit. She has struggled to afford her prescription medications since.
“What I’m making is nothing,” Mastrototaro said. “I am scavenging just to make ends meet.”
The Gaetz-led proposal ignores “the hard realities of what it takes to be qualifying for Medicaid in Florida,” said Scott Darius, executive director of Florida Voices for Health, a nonprofit that advocates for Medicaid expansion. “On its face,” he said, “it doesn’t make sense.”
Medicaid experts say the federal budget reconciliation law holds that nonexpansion states cannot adopt work requirements.
A state that hasn’t added more low-income adults to its Medicaid program can’t impose work requirements on those who are already covered, Cuello said. States must cover specific categories of low-income people — such as children, pregnant women, some parents, older adults, and people with disabilities — to receive federal funding for their programs.
States that have expanded Medicaid eligibility to a limited group of low-income adults, namely Georgia and Wisconsin, will be required to impose work requirements on those enrollees.
Georgia’s partial expansion program, launched in July 2023, already includes a requirement that newly eligible adults report at least 80 hours of work or community engagement. Federal approval for the program expires at the end of December, and the state has applied for an extension. Wisconsin’s program will have to implement a work requirement by Jan. 1.
South Carolina applied in June for federal approval to extend Medicaid eligibility to nondisabled parents and caregivers ages 19 to 64 who earn 67-100% of the federal poverty level. That’s about $18,300 to $27,300 a year for a family of three. The state’s application is pending with CMS, and if approved would implement work requirements for those newly eligible adults.
Gaetz said if the Florida legislation were approved, the state would develop a “business plan” for implementing work requirements and seek CMS approval.
It is unclear how much it would cost, but experience in states with Medicaid work requirements suggests that implementation would be expensive. States must upgrade their eligibility and enrollment systems, hire additional staff, and inform the public of the new mandate.
For its program, Georgia spent about $54.2 million on administrative changes out of $80.3 million in total spending for the program from October 2020 to March 2025, according to a report from the U.S. Government Accountability Office. Most of the administrative spending — about $47.4 million, or 88% — came from the federal government.
Georgia’s experience echoes others’, according to a 2019 GAO examination of states that received approval to implement Medicaid work requirements during the first Trump administration. That report focused on five states — Arkansas, Indiana, Kentucky, New Hampshire, and Wisconsin — and estimated costs would total $408 million. They ranged from $6 million in New Hampshire to more than $270 million in Kentucky, though those figures did not reflect all the state costs.
Florida’s computer infrastructure for collecting and verifying information and determining eligibility is more than 30 years old and is being replaced. That is anticipated to be completed in 2028 and cost more than $180 million.
A legislative analysis of Gaetz’s bill estimated that if 1 in 4 people affected by the proposed work requirement were to lose Medicaid coverage, the state could save about $80 million a year.
Darius, with Florida Voices for Health, said those potential savings hardly seem worth the effort.
“It requires the state to build this giant regulatory-like framework and to rebuild systems, and to employ a whole set of people to chase down the very small number of folks who would ultimately be touched by this,” he said.
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