Earlier this month, Nebraska became the first state to implement the Medicaid work requirements established by last year’s One Big Beautiful Bill Act — now renamed by Republicans as the working families tax cuts. Dozens of others are scrambling to follow suit before the January deadline.
Democrats and much of the media have portrayed work requirements as a cruel and unnecessary attack on healthcare access — one that could deprive millions of people of coverage.
Recommended Stories
What’s missing from this pat narrative, however, is any acknowledgment of just how costly and dysfunctional Medicaid has become.
MINNESOTA OFF-LOADS FRAUD CASES ONTO FEDERAL INVESTIGATORS DUE TO OVERWHELMING BACKLOG
Thanks to Obamacare’s expansion of the entitlement — which extended eligibility to able-bodied adults with incomes up to 138% of the federal poverty limit, or just over $22,000 for an individual — Medicaid has ceased to be a safety-net initiative. It is now the nation’s single largest coverage provider, insuring 1 in 5 Americans — and nearly 4 in 10 patients in my home state of California.
This astounding growth hasn’t come cheap. The newly eligible Medicaid population costs taxpayers nearly $180 billion a year — at a time when overall program spending is growing at an unsustainable clip, totaling 8.6% in 2025 alone.
But cost is just one of the ways Obamacare’s expansion has wreaked havoc on the program.
Obamacare also committed the federal government to paying for the overwhelming majority — currently 90% — of the costs for these expansion enrollees. By contrast, the feds cover between 50% and 77% of the cost of legacy enrollees: children, pregnant women, and the disabled.
Medicaid’s growth isn’t sustainable. And it’s unjust to pay states more for signing up able-bodied adults than the destitute people Medicaid was created to serve.
Mandatory work requirements will restore a bit of sanity to the program. Able-bodied, working-age expansion enrollees will need to spend at least 80 hours a month working, volunteering, or pursuing their education as a condition of eligibility. It works out to 20 hours a week — the equivalent of a part-time job.
That’s hardly an excessive price to pay for free, taxpayer-funded health insurance.
Sally C. Pipes is president, CEO, and Thomas W. Smith Fellow in Health Care Policy at the Pacific Research Institute. Her latest book is The World’s Medicine Chest: How America Achieved Pharmaceutical Supremacy—and How to Keep It (Encounter 2025). Follow her on X @sallypipes.
