Medicaid Work Requirements Need Real Enforcement
The text argues that Medicaid work requirements for able-bodied,working-age adults should be accompanied by strong verification-following Ronald Reagan’s “trust,but verify” approach-because incentives to cheat make verification essential.
It claims that while federal funding under Obamacare gives states much higher payments for able-bodied adults than for traditional Medicaid groups (children, pregnant women, seniors, people with disabilities), Medicaid program integrity safeguards are needed to protect vulnerable people and constrain spending abuses.
The article says exemptions to the work requirement (for disability, caregivers, and those considered “medically frail”) should not be handled through self-attestation or simple checkbox claims. It points to experience in the Affordable Care Act (ACA), where a Biden-era shift toward relying more on self-attestation for income verification-especially for heavily subsidized plans-contributed to millions of improper enrollments and tens of billions in improper subsidy spending.
As a contrast, it cites Louisiana’s decision to reduce self-reporting and require regular data crosschecks, supported by findings that a large share of sampled enrollees were ineligible but remained enrolled.
it argues that concerns about people struggling to get medical documentation are overstated because Medicaid can cover services retroactively and states must provide advance notice. It concludes that Medicaid has strong incentives to maximize enrollment (benefiting enrollees, insurers, providers, and brokers), so verification-not blind trust-is necessary. It also says the Trump administration should avoid repeating the kinds of verification loosening associated with ACA enrollment fraud.
President Ronald Reagan famously embraced the Russian proverb “Trust, but verify” during negotiations with the Soviet Union over nuclear arms reductions. Reagan understood that when there are incentives to cheat, verification is essential.
That same principle applies to government welfare programs, including the forthcoming Medicaid work requirements. In the Working Families Tax Cut Act — also known as the One Big Beautiful Bill — Congress required able-bodied, working-age adults to work, volunteer, or participate in job training to receive Medicaid unless they qualify for an exemption. More than 80 percent of Americans support such requirements.
The work requirements are more important because of Obamacare. The federal government pays states roughly seven times more for able-bodied, working-age adults on the program per state dollar than it does for traditional Medicaid enrollees — such as children, pregnant women, seniors, and individuals with disabilities. To protect the most vulnerable, the federal government must put guardrails on spending for expansion enrollees.
The work requirements do not apply to people with disabilities, parents with young dependents, or those deemed “medically frail.” Crucially, work is essential for upward mobility and a more stable life.
Unfortunately, some states are gearing up to permit applicants (or intermediaries enrolling them on their behalf) to self-attest to meeting the requirements or qualifying for an exemption. These states would permit applicants to simply check a box without verification.
Failing to verify applicant information has led to widespread improper enrollment and fraud in other programs. The massive improper enrollment in the Affordable Care Act (ACA) proves that when the government weakens verification standards, including through self-attestation, improper enrollment rises dramatically.
In 2024, the Biden administration loosened eligibility verification for heavily subsidized ACA plans and expanded reliance on applicant self-attestation. Previously, applicants whose income could not be verified generally had to submit documentation before receiving subsidized coverage. Beginning in 2024, exchanges were required to accept self-attestation when income could not be verified through tax data.
This decision had predictably harmful consequences, especially when combined with expanded ACA subsidies that fully subsidized plans for individuals claiming low incomes. Our Paragon colleagues assessed sign-ups with Census Bureau data and found 5 million improper enrollees in 2024 — the same year the self-attestation policy took effect. This corresponded to upwards of $20 billion of improper subsidy spending that year. In Florida alone, 2.7 million people enrolled after claiming the lowest possible income to receive the largest subsidies, roughly 4.5 times the number eligible.
Weak verification standards, including self-attestation, enabled applicants and commission-driven brokers to misstate income. By removing the documentation requirement and requiring exchanges to accept self-attestation, the Biden administration undermined a commonsense program integrity measure.
In stark contrast to the Biden-era approach, the state of Louisiana recognized the danger of self-attestation. Auditors found that 93 percent of sampled Medicaid enrollees in Louisiana were ineligible yet remained enrolled, in part, because the state allowed individuals to self-report changes in their wages. Louisiana enacted a bill under Gov. Jeff Landry that requires regular data crosschecks and bans self-attestation in many cases.
Similarly, the Trump administration should require a “trust, but verify” policy for meeting the work requirement and qualifying for an exemption nationwide. If an applicant claims medical frailty, they should be required to submit documentation from a medical professional. This commonsense safeguard would prevent individuals from gaming the system and improperly taking advantage of an exemption meant for people with medical conditions that make work exceedingly difficult.
Some contend that people would struggle to obtain medical documentation because doing so requires a doctor’s appointment, which might be difficult without Medicaid coverage. But that ignores how Medicaid retroactively covers services. Moreover, the Working Families Tax Cut already requires states to provide enrollees with advanced notice to minimize disruption.
The incentives within Medicaid strongly favor maximizing enrollment. Applicants receive free or heavily subsidized coverage, insurers gain premium revenue, providers benefit from additional reimbursable services, and brokers receive commissions. These incentives reduce the likelihood that stronger documentation requirements would meaningfully disrupt coverage for eligible individuals while reinforcing the need for stronger program integrity efforts to ensure that only eligible individuals are enrolled.
This year, the Trump administration has rightly targeted fraud and reversed Biden policies that enabled improper ACA enrollment to skyrocket. Allowing self-attestation in Medicaid would return us to the Biden administration’s policy failures. The American people overwhelmingly support commonsense work requirements for able-bodied adults receiving welfare benefits, not policies that can be so easily gamed. When spending other people’s money on other people, verification — not blind trust — is the prudent policy.
Chris Medrano is a legal research analyst at Paragon Health Institute. Brian Blase is President of Paragon Health Institute.
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