States Scramble to Implement Trump’s Medicaid Work Requirements Amid Uncertainty and AI Solutions

State officials across the U.S. are grappling with how to enforce Medicaid work requirements for adult enrollees, even as one state prepares to launch its program this week. A KFF survey of Medicaid officials from 42 states and the District of Columbia reveals the challenges and uncertainties they face ahead of the January 1, 2027 deadline for implementation.

Key questions include which illnesses and conditions will qualify beneficiaries for exemptions and how to automate compliance verification. Federal guidance is not expected until June, leaving states to define terms like “medical frailty” independently. This flexibility stems from the One Big Beautiful Bill Act, a law signed by President Donald Trump that revamps Medicaid in over 40 states and Washington, D.C., expanding coverage to low-income adults without dependent children.

While most adult Medicaid beneficiaries already work or are disabled, caregivers, or students, Republicans argue that non-working enrollees divert resources from vulnerable groups like children, pregnant women, and the disabled. The expansion under the Affordable Care Act, which most Republicans oppose, added about 20 million people to Medicaid rolls.

The new work rules mandate that enrollees work or participate in qualifying activities—such as community service or part-time education—for at least 80 hours per month. These rules apply to current enrollees and could significantly alter Medicaid eligibility.

The Congressional Budget Office estimates the work requirements will reduce federal Medicaid spending by $326 billion over 10 years and leave 4.8 million more people uninsured by 2034.

States Take Diverse Approaches to Enforcement

Amaya Diana, a policy analyst at KFF who contributed to the survey, noted that states are operating on a “super-condensed timeline.” She said,

“A lot of states are working on a super-condensed timeline. They are still making these big decisions with less than a year before implementation.”

States are adopting varied strategies to enforce the requirements, including the use of artificial intelligence in some cases. However, the lack of federal guidance has led to inconsistencies in policy decisions.

The law allows short exemptions for enrollees facing hardships, such as natural disasters, high local unemployment, hospital admissions, or extended medical travel. While 28 states and Washington, D.C. will offer hardship exemptions, three states—Iowa, Indiana, and one other—will not adopt all four permitted exemptions, and two of these states plan to offer no exemptions at all.

Enrollees may also qualify for exemptions if deemed “medically frail,” but the federal government has not yet defined this term or established criteria for determining eligibility.