The Trump administration has issued final rules on how states should ensure that millions of Medicaid enrollees prove they’re working or completing other activities, such as job training, volunteering, or being enrolled in an educational program.

The Centers for Medicare & Medicaid Services released the rules on June 1. That deadline was set last year in the GOP tax-and-spending law known as the One Big Beautiful Bill Act, which established a work requirement for certain people enrolled in Medicaid, the state-federal health insurance program for people with low incomes or disabilities.

Medicaid agencies are scrambling to rework IT systems and make sure they have staff to effectively enforce the rules, while also keeping enrollees from losing coverage for administrative reasons, such as difficulty navigating state eligibility portals.

The newly announced regulations offer a clearer picture of what roughly 18.5 million Medicaid enrollees will have to do to prove they qualify for benefits.
Jim Torres, who helps people enroll in health coverage at the Samuel U. Rodgers Health Center in Kansas City, Missouri, said a “very small percentage” of his clients have heard of the changes coming to Medicaid.

“These folks have very busy lives. They’re doing the best they can to get by,” he said. “It’s just not a top-of-mind thing for most of them.”
Health policy researchers and consumer advocates said enrollees should keep a few things in mind as the Jan. 1, 2027, rollout approaches in most states.

1. The Work Rules Won’t Apply to Everyone.

The new rules will apply to people covered through what’s known as Medicaid expansion. Since 2014, more than 40 states and the District of Columbia have decided to allow more people into their Medicaid programs, generally low-income adults without dependents. Georgia and Wisconsin offer coverage to some people in this group, so they’ll be subject to the rules.

Children and pregnant people, as well as individuals with disabilities who receive Social Security payments — all groups that already qualify for Medicaid — won’t be subject to the rules. Nor will people determined to be “medically frail,” or too sick to work.

People subject to the work rules are “crowding out” people in the Medicaid program who are “truly in need,” CMS Director Mehmet Oz claimed during a June 1 press call. “Work requirements are going to turn this around, we hope.”

The rules are set to take effect in most places in January. Nebraska started enforcing them in May. Montana plans to start in July but won’t kick people off until October. Arkansas will do a “soft” launch in July — it will start enforcing the rules but with no penalties until next year.

2. States Will Take Your Word That You’re Too Sick To Work. For Now.

Federal officials have stressed that states should make the process of reporting hours and requesting exemptions as simple as possible for Medicaid enrollees by creating automated systems and using existing data sources, such as unemployment and education records.

If states cannot determine you’re performing 80 hours of qualifying activities a month using those data sources, you may be allowed to “self-attest” to that in 2027, health policy researchers said.

People will also be allowed to “self-attest” that they are too sick to work in 2027, and do so one time in 2028. Then states will start asking for proof, if they can’t find it through available data.

But after the initial rollout, the burden of proof is likely to still fall on many enrollees, said researchers and consumer advocates.

People may need to dig up pay stubs, medical records, and doctors’ notes and submit them for state review, said Morgan Henderson, who has studied Medicaid work programs in Georgia and Arkansas at The Hilltop Institute, a research center at the University of Maryland-Baltimore County.

“The higher this manual reporting burden, the less people are going to do it,” he said. “That means that we’re going to see coverage drop-offs.”

3. The Rules Are Tougher Than Expected for People Too Sick To Work.

One of CMS’ primary goals has been to “protect vulnerable populations” through “strong exemptions to make sure people who can’t reasonably be expected to work are not subject to the requirements,” Dan Brillman, a deputy administrator at the agency, said during the June 1 press call.
Consumer and patient advocates, however, said the final rules’ exemptions are more restrictive than expected. Enrollees will eventually have to provide documentation, such as a statement from a medical professional, to prove that a health condition keeps them from working. And each individual state will have to determine the severity of beneficiaries’ medical conditions.

“Someone could be medically frail in Nebraska but not medically frail in Delaware,” said Carolyn Sheridan, associate director of state policy for the National Organization for Rare Disorders, which lobbies for patients with rare diseases. She said her group had hoped the rules would offer a standardized definition of who counted as medically frail and not leave the decision up to states.

Trump administration officials have publicly crusaded against fraud in government health programs, such as Medicaid, and states could face financial penalties for incorrectly granting people exemptions from the work rules, said Jennifer Tolbert, who researches Medicaid at KFF, a health information nonprofit that includes KFF Health News.

“States may be more cautious,” she said. “That will likely lead to people losing coverage who may still be eligible.”

4. Only Certain Qualifying Activities Count.

Enrollees can satisfy the rules by working 80 hours a month. They can also be enrolled in college courses, volunteer through a community organization, or do “in-kind” work that doesn’t result in pay.

The rules set out, in detail, how many academic credit hours translate to 80 hours a month — students need to be enrolled in six credit hours per semester to meet the “half-time” requirement. An unpaid internship can count toward the 80 hours.

People can also prove they’re volunteering with “a document from a community service organization.”

Consumer advocates say it might be hard for people to obtain proof they’re performing these kinds of informal activities. But supporters of the rules say volunteerism can already be tracked.

“If you run into trouble with the law and the judge says, ‘Hey, you need some volunteering and community service to serve your time,’ there are already ways that we verify that,” said Niklas Kleinworth, who works on state health policy for the conservative Paragon Institute.

5. You Have Time To Prepare.

Make sure your state Medicaid agency has your current mailing address and keep your eye on your mailbox, said researchers and consumer advocates. State Medicaid agencies must inform you in two ways if you’ll be subject to the rules — by either regular mail or email, and by one other form of communication, such as a text or phone call or by posting a notice online.

“The important stuff comes by mail,” Henderson said.

And check in with your state Medicaid agency, said researchers and advocates. Some states, including Arkansas, California, and Wisconsin, have already posted information about the work rules on their websites. If you can’t find what you’re looking for there, visit or call a local office. A caseworker should be able to tell you whether you’ll be subject to the rules.

“Get ahead of this,” said Joan Alker, who is executive director of the Georgetown University Center for Children and Families and studies Medicaid. “So that you don’t end up going to the pharmacy one day and they say ‘Oh, you’re not insured anymore’ when you’re trying to get your prescriptions refilled.”
KFF Health News correspondent Samantha Liss and senior correspondent Rachana Pradhan contributed to this report.

Have you tried to prove your eligibility for Medicaid under new rules that require people to show they are working, going to school, or participating in another qualifying activity? Click here to contact KFF Health News.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

Nearly 200 residents at the St. Joseph’s Center nursing home in the affluent Connecticut suburb of Trumbull were evacuated last year after Legionella bacteria was found in the facility’s water system. Two months later, they were evacuated again over critical failures in the building’s fire safety systems.

Three years earlier, residents at another Connecticut nursing home, the Quinnipiac Valley Center, were relocated after two resident deaths triggered a state health investigation.

The nursing homes were both owned by private equity-backed Genesis HealthCare, among the largest skilled nursing operators in the nation. It’s already faced lawsuits or investigations in California, Georgia, Massachusetts, Missouri, Nevada and Vermont over allegations of patient neglect and abuse.

This year, Connecticut enacted what may be the strongest law in the country addressing transparency and accountability for private equity-owned nursing homes.

It is the latest in a string of states stepping into a regulatory vacuum created by limited federal laws and a presidential administration that’s proven friendly to private equity while showing little appetite for scrutinizing private equity’s role in the healthcare industry.

Private equity’s foray into healthcare over the past several years, particularly into hospital ownership, has drawn public outrage and legislative scrutiny.

It’s all happening as states are staring down steep federal cuts to Medicaid, the public health insurance for people with low incomes that is also the primary payer for long-term nursing home stays. Those cuts, experts fear, could ultimately direct more older Americans into nursing home care.

Last year, at least seven states (California, Indiana, Massachusetts, Maine, New Mexico, Oregon and Washington) passed legislation putting more guardrails around private equity’s involvement in healthcare.

Virginia is still considering a bill to curb predatory property financing practices that have been used by private equity in nursing homes.

Illinois lawmakers sent two measures to Democratic Gov. JB Pritzker that aim to strengthen oversight and transparency requirements of healthcare mergers or acquisitions, and place new restrictions on private equity ownership of disability service providers. The first bill was Democratic-sponsored, while the second had both Democratic and Republican sponsors.

Democratic Gov. Ned Lamont signed Connecticut’s measure last week. The new law requires nursing homes that are owned by private equity to disclose their financial dealings with the state and bans private equity from controlling day-to-day care decisions about nursing home residents. Lamont also signed a related bill to curb private equity’s influence over hospitals in the wake of financial moves by equity-owned health groups in his state that led to hospital closures.

Genesis HealthCare declined an interview with Stateline, but provided a statement saying it “remains focused on supporting our affiliated centers in delivering high-quality care to patients and residents.”

The nursing home industry argues that private equity controls a relatively small share of the nation’s facilities, and that reported problems have been the result of a few bad actors. The federal government estimated that about 5% of Medicare-enrolled nursing homes nationwide had private equity owners in 2022, but admitted that some nursing homes don’t always list all of their owners in the federal database. Some researchers have pegged the real share as high as 13%.

“Focusing on private equity in long term care has become a distraction from the real issues that impact the majority of providers, like chronic Medicaid underfunding and a growing caregiver shortage,” said John Kane, a senior vice president at the industry group American Health Care Association/National Center for Assisted Living, in a statement to Stateline.

“If we truly want to improve care throughout the health care system, we need policymakers to find a proper balance of oversight while still encouraging more investments.”

But a growing number of states are moving to regulate investment companies that draw heavily on Medicaid and Medicare dollars.

“The big question about private equity is not whether profit belongs in the nursing home; it’s whether public dollars meant for care are being converted into financial returns (for investors) without enough accountability,” said Gregory Orewa, an assistant professor at the University of Texas at San Antonio whose research has focused on private equity ownership in U.S. healthcare.

“Nursing homes exist to care for the most vulnerable who cannot care for themselves,” he said, “so we should be holding private equity or anybody to high standards on providing quality care.”

Quality and profits

Private equity firms use pooled investments from pension funds, sovereign wealth funds, endowments and wealthy individuals to buy a controlling stake in a company. Then they try to maximize the company’s value before selling it at a profit, usually within a few years.

Nursing homes and other long-term care facilities are attractive to investors because demand is always there; the share of Americans 65 and older has been steadily rising and is expected to continue.

Nursing home care is heavily subsidized by the government through Medicaid and to a lesser extent Medicare, the public insurance program for adults over 65 and some people with disabilities, offering investors a predictable revenue stream.

And it’s an industry where investors can scoop up struggling independent facilities and improve their margins through corporate consolidations, streamlining management, adjusting staffing or capitalizing on valuable real estate owned by the nursing homes.

Private equity’s defenders say it provides nursing homes with much-needed capital, disciplined management and operational improvements that help facilities scale up their services.

But the private equity model’s primary goal in any sector is to generate returns for shareholders, usually within a few years.

Critics say that priority conflicts with the kind of long-term investment that’s needed to provide quality healthcare, such as paying enough to hire sufficient staff or upgrading facilities.

“One of the biggest misunderstandings is that private equity ownership is only bad,” said Orewa, of the University of Texas at San Antonio. “The issue is more structural. Nursing homes operate on very thin margins, they depend heavily on public dollars and they care for the most vulnerable people who can’t easily exit when nursing home quality declines.”

Nursing home residents aren’t like other healthcare consumers. They may lack financial literacy, or their decision-making may be impaired by cognitive decline, which could lead to them making choices not in their best interests, researchers have noted. They’re a captive audience, often choosing a facility that’s nearby or near family, rather than shopping around for the best option.

Research on how private equity ownership affects nursing homes has found few positive effects. One large 2023 study found it increases a nursing home’s death rate by 11%. Private equity-owned facilities tended to maintain care quality for sicker patients by adding registered nurses, but researchers found those gains were offset by staffing cuts to the frontline nursing assistants who handle most of the hands-on care. Other studies have linked private equity involvement to increases in emergency room visits and rising Medicare costs.

Orewa and his colleagues published a comprehensive review last year of a dozen major studies, linking private equity ownership to a higher number of deficiencies in nursing homes, increased hospitalization rates and higher mortality. They also found that private equity-owned facilities bill Medicare more than other nursing homes.

Facilities’ financial outlooks initially improved after a private equity buyout, Orewa said, but they later faced long-term challenges. The financial maneuvers that private equity uses to extract more revenue from nursing homes can hurt their stability long term.

Hidden disclosures

All nursing homes that receive federal funding are required to publicly disclose the names of any entities that exercise financial control over them. But companies can use complex methods to mask that ownership, meaning it’s difficult even for experts to find out who really owns a nursing home.

“A lot of nursing homes will not provide that information, and their information may not be audited,” said Michael Fenne, healthcare policy coordinator at the Private Equity Stakeholder Project, a research group that tracks the private equity industry.

For example: The private equity-backed Portopiccolo Group acquired more than 130 nursing homes across 9 states from 2016-2022 and yet didn’t appear in federal data as an owner of those facilities, according to the consumer advocacy nonprofit Public Citizen.

And ownership information matters to consumers looking for a safe place for their loved ones: The Portopiccolo Group’s nursing homes have faced heavy fines. A 2023 study by watchdog group Good Jobs First found Portopiccolo had an average fine per facility of more than $81,000, landing it on a list of parent companies with largest average penalties in the U.S.

Predatory tactics?

Virginia lawmakers are considering a Republican-sponsored bill that would cut funding to nursing homes that pay excessive rents to landlords. If passed, it could become a first-in-the nation effort to directly curb a financial maneuver known as sale-leaseback that state regulators have deemed predatory.

In sale-leaseback arrangements, a private equity-backed firm buys a healthcare company, such as a nursing home chain, and then sells its underlying real estate property to a separate investment trust. This sale generates quick returns for investors but saddles the nursing homes with monthly rent payments they may struggle to make, leaving less money available for patient care.

It’s a tactic that has contributed to healthcare bankruptcies across the nation, including for Genesis HealthCare and for Georgia-based nursing home chain LaVie Care Centers.

Increased need for nursing homes

By 2030, 1 in 5 Americans will be 65 or over, and most older adults say they would prefer to remain living in their homes for as long as possible.

For many, that’s possible because of services — such as home health aides or visiting nurses — that are funded through Medicaid.

But elder care experts worry those services will be the first on the chopping block for cash-strapped states facing $665 billion in Medicaid cuts over the next decade from President Donald Trump’s One Big Beautiful Bill Act. This is because federal law requires state Medicaid programs to cover nursing home care, but home-based services are optional.

Most people who receive those home-based Medicaid services need the kind of care that would land them in a nursing home without such services, said Jason Resendez, president and CEO of the advocacy group National Alliance for Caregiving.

“When we take those benefits away, it doesn’t take away the need for that care,” he said. One of the impacts of cuts to home-based services “will certainly be more folks forced to make the hard choice of going into more institutional-based care.”

And cuts to Medicaid could financially weaken smaller, independent or safety-net nursing homes that serve lower-income patients who heavily rely on Medicaid.

“Those distressed facilities may become cheaper acquisition targets for private equity,” Orewa said. “That creates an opportunity for investors with capital to buy at a discount.”

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.

WASHINGTON — Voters, including those within the Make America Healthy Again movement, say the rising cost of healthcare is a significant concern that will have an impact on whom they support in November’s midterm elections, according to a poll released Wednesday by KFF. 

Sixty-one percent of respondents to the survey, which asked how important several health-related issues were, said the price of healthcare will have a major impact on which party they support as control of Congress hangs in the balance.

Among MAHA voters, who are predominantly Republicans but also include independents and some Democrats, 42% said cost is their top issue heading into the elections. 

“While the issue of health costs is more salient for Democratic voters than for Republicans, larger shares across partisans say health costs will have a major impact on their voting decisions than say the same about vaccine policy or food safety,” the survey said. 

Seventy-two percent of Democrats, 63% of independents and 47% of Republicans said the cost of healthcare will have a major impact on which party’s candidate they vote for. 

Vaccine policy came in next, with 57% of Democrats, 46% of independents and 32% of Republicans surveyed saying it will have a major impact on their choice. 

Issues related to food safety came in third after 43% of Democrats, 40% of independents and 38% of Republicans responded that it will have a major impact on their choice of candidate.  

MAHA issues 

For MAHA voters, twice as many listed health costs as their first priority than the next issue: restricting the use of certain chemical additives in food, which was a key concern for 21%.

Ten percent were interested in politicians who will reevaluate vaccine approvals, 8% want lawmakers to limit corporate interest in food and 8% want Congress to limit the use of pesticides in agriculture. Eleven percent said none of those or had no answer. 

The survey showed that a significant majority of Americans across the political spectrum believe the government hasn’t done enough to address chemical additives in food or pesticide use in agriculture, two core demands of MAHA supporters.  

“The public perception that there is not enough regulation may be rooted in broader skepticism toward the industries themselves,” the survey said. “Most U.S. adults do not trust pharmaceutical companies, food and beverage companies, or agricultural companies to act in the public’s best interest.”

Doctors and healthcare providers were the most trusted source of information at 70%, followed by agriculture companies at 40%, food and beverage companies at 25% and pharmaceutical companies at 21%. 

Seventy-five percent of those polled said the government hasn’t done enough to regulate chemicals in food, while 65% said it should do more to regulate pesticides in agriculture. 

The poll of 1,343 U.S. adults took place from April 14 to April 19. It has a margin of error of 3 percentage points for the full sample and 6 percentage points for MAHA supporters.

Massachusetts and Rhode Island are considering dropping GLP-1 drugs for obesity treatment from their Medicaid programs, continuing a trend of states that have stopped coverage of these expensive medications. 

Thirteen state Medicaid programs are covering GLP-1 drugs for the treatment of obesity this year, down from 16 last year. 

Medicaid programs in California, New Hampshire, Pennsylvania and South Carolina have eliminated coverage of the drugs for weight loss, because the expense strained state budgets. 

In Massachusetts, the governor’s proposed fiscal 2028 budget would not fund the state’s Medicaid program, MassHealth, to cover GLP-1 medications for weight loss alone, though the state would continue covering the drugs for diabetes and other conditions. The legislature is still debating the state budget. 

Rhode Island’s governor also has proposed removing GLP-1 coverage from the state’s Medicaid program for weight loss treatment. 

North Carolina reinstated such coverage in mid-December after having dropped it in October. 

Medicaid programs in Delaware, Kansas, Michigan, Minnesota, Mississippi, Missouri, Tennessee, Utah, Virginia and Wisconsin also cover the drugs for obesity treatment, according to KFF, a health policy research group. 

But some states, such as Michigan, have restricted eligibility for these medications to morbidly obesity patients rather than those who are overweight or obese. The move is expected to save the state an estimated $240 million. 

Meanwhile, lawmakers in Louisiana are debating whether to allow Medicaid to cover GLP-1s for obesity treatment if enrollees have another chronic condition, or comorbidity, such as prediabetes, hypertension or cardiovascular disease.  

The medications generally have been too expensive for people without insurance. In February, one of the largest producers of these drugs, Novo Nordisk, announced it would reduce their list prices to $675 per month in 2027. 

Gross spending on Medicaid prescriptions for GLP-1s — for diabetes as well as for weight loss — has increased from around $1 billion in 2019 to almost $9 billion in 2024 as demand for these drugs has risen, according to KFF. 

At the same time almost 40% of adults and a quarter of children with Medicaid have obesity and may benefit from having access to the drugs, according to KFF. 

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.