The Hidden Face of Medicaid Work Requirements: How Middle-Aged Women Are Being Left Behind

A Personal Struggle with Vision and Survival

Lori Kelley’s story is one that challenges the political narratives surrounding Medicaid reform. At 59 years old, the Harrisburg, North Carolina resident faces a daily battle that many don’t see—literally and figuratively. Her deteriorating vision has transformed from a personal health challenge into a barrier that affects every aspect of her livelihood. Last year, she was forced to close her nonprofit circus arts school, a passion project that had likely brought joy to her community, simply because she could no longer see well enough to complete basic paperwork. The administrative tasks that most of us take for granted—reading forms, managing documents, keeping records—had become impossible obstacles. She then tried working at a pizza shop making dough, using her hands where her eyes failed her. Today, she sorts recyclable materials at a local concert venue, a job that accommodates her visual limitations. Her employer knows her situation and accepts her as she is, creating a rare workplace environment where she doesn’t have to repeatedly explain why she can’t read certain materials. But this understanding employer can only offer seasonal work, leaving Kelley to survive on less than $10,000 annually while living in a camper. Her Medicaid coverage has been a lifeline, providing medications for arthritis and anxiety, and enabling crucial doctor visits to manage her high blood pressure. Now, facing new work requirements demanding 80 hours of qualifying activities monthly, she’s terrified of losing the healthcare that keeps her functional.

The Reality Behind Political Rhetoric

The political justification for Medicaid work requirements has painted a particular picture of who benefits from the program. House Speaker Mike Johnson’s comment to CNN characterized the issue as being about “29-year-old males sitting on their couches playing video games,” suggesting that young, able-bodied men are exploiting government healthcare. This narrative has been politically powerful, resonating with those who believe in stricter welfare requirements. However, research reveals a dramatically different reality. According to Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, adults ages 50 to 64—particularly women—are the demographic most likely to face hardship under these new rules. Starting in January 2027, approximately 20 million low-income Americans across 42 states and Washington, D.C., will need to meet activity requirements to maintain their Medicaid coverage. Eight states that didn’t expand Medicaid under the Affordable Care Act won’t implement these requirements, but that’s only because they’ve already limited coverage to the most vulnerable populations. The nonpartisan Congressional Budget Office has projected that at least 5 million fewer people will have Medicaid coverage over the next decade as a direct result of these work rules. These requirements represent the largest driver of coverage losses in the GOP budget law, which critics argue cuts nearly $1 trillion in healthcare spending primarily to offset tax breaks benefiting wealthy individuals and corporations while increasing border security funding.

Who Really Needs Medicaid?

Jane Tavares, a gerontology researcher at the University of Massachusetts Boston, sees these policy changes as fundamentally misguided. Her research challenges the stereotypes driving the legislation: “We’re talking about saving money at the expense of people’s lives. The work requirement is just a tool to do that.” The data tells a compelling story that contradicts political assumptions. Research shows that only 8% of the total Medicaid population is considered “able-bodied” and not working. Rather than healthy young adults “just hanging out,” this group consists largely of very poor women who have left the workforce to become caretakers—and one in four of them are 50 or older. Medicaid currently covers one in five Americans ages 50 to 64, providing essential health coverage during the vulnerable years before Medicare eligibility at 65. Georgetown University researchers have found that Medicaid expansion has been a critical lifeline for middle-aged adults who would otherwise lack insurance entirely. Among women on Medicaid, those ages 50 through 64 face unique challenges: they’re less likely to meet work hour requirements because many serve as family caregivers or have illnesses limiting their ability to work, yet they’re more likely to need substantial healthcare services than younger enrollees. The Department of Health and Human Services defends the policy, with spokesperson Andrew Nixon stating that requiring “able-bodied adults” to work ensures Medicaid’s “long-term sustainability” while protecting it for the vulnerable. Exemptions exist for people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship—but advocates worry these exemptions are too narrow and difficult to navigate.

The Sandwich Generation’s Impossible Choice

The term “sandwich generation” describes people caught between caring for aging parents and supporting children, often at the expense of their own careers and wellbeing. This demographic faces particularly cruel consequences under the new Medicaid work requirements. Nicole Jorwic, chief program officer for Caring Across Generations, explains that while the GOP budget law does allow some caregiver exemptions, these carve-outs are “very narrow,” creating significant risk that eligible people will slip through bureaucratic cracks. The real-world impact extends beyond individual hardship to family crisis. When caregivers lose health coverage, they become sicker themselves, continuing to postpone their own medical needs while trying to care for others. This creates a cascading effect: families end up in crisis situations, the caregivers’ health deteriorates, and ultimately the healthcare system faces greater costs when these individuals finally seek emergency care or age into Medicare with more advanced, expensive conditions. Ironically, making it harder for people to maintain Medicaid coverage “may actually undermine their ability to work” because their health problems go untreated, as Tolbert points out. A person who can’t afford medication for high blood pressure, diabetes, or mental health conditions becomes less capable of maintaining employment, not more so. The policy assumes that removing healthcare access will motivate work, but the reality is that untreated health conditions make work impossible for many middle-aged adults already struggling with the physical challenges of aging.

Paula Wallace’s Dilemma

Paula Wallace’s situation in Chidester, Arkansas, illustrates how these policies affect real families. At 63, Wallace spent most of her adult life working and contributing to society. Today, her full-time job is caring for her husband, who suffers from advanced cirrhosis. After years of being uninsured—a precarious situation at her age when health issues typically emerge—she recently gained coverage through Arkansas’s Medicaid expansion. Now she faces the prospect of losing that coverage unless she can meet work requirements that seem impossibly incompatible with her current responsibilities. “With me being his only caregiver, I can’t go out and work away from home,” she explains. The law technically should exempt her as a full-time caregiver for someone with a disability, since her husband receives Social Security Disability Insurance. But federal officials have yet to issue specific guidance on how to define and apply that exemption. The experiences from Arkansas and Georgia—the only states to have previously run Medicaid work programs—offer little comfort. Both states saw many enrollees struggle to navigate complicated benefits systems, often losing coverage despite technically qualifying for exemptions. The bureaucratic complexity meant that people who should have kept their coverage lost it anyway, not because they were ineligible but because they couldn’t successfully navigate the administrative maze. For Wallace, this creates tremendous anxiety. She’s caught between caring for her seriously ill husband and potentially losing the healthcare coverage that allows her to remain healthy enough to provide that care. It’s a catch-22 that policymakers seem not to have considered or, perhaps worse, not to care about.

The Long-Term Costs of Short-Term Savings

Health policy researchers warn that the supposed savings from Medicaid work requirements may actually cost the healthcare system more in the long run. Adults often begin wrestling with chronic health issues in their 50s and early 60s—precisely the population most affected by these requirements. If older adults lack the means to address emerging health problems before they turn 65 and qualify for Medicare, they’ll enter that program significantly sicker, requiring more expensive interventions and ongoing care. Preventive care and early treatment of conditions like high blood pressure, diabetes, and heart disease are far less expensive than treating these conditions after they’ve progressed to advanced stages. A person who can’t afford blood pressure medication in their late 50s may suffer a stroke in their mid-60s, requiring extensive rehabilitation and ongoing care that costs Medicare exponentially more than the preventive medication would have cost Medicaid. Similarly, untreated diabetes can lead to kidney failure, amputation, and blindness—all catastrophically expensive conditions. The policy essentially shifts costs from Medicaid to Medicare while worsening health outcomes for vulnerable Americans. Beyond the financial calculations, there’s a fundamental question of values. Tavares frames it starkly: these policies save money “at the expense of people’s lives.” For someone like Lori Kelley, losing Medicaid doesn’t just mean higher costs in the future—it means potentially losing access to the medications and care that allow her to function day-to-day, work the limited hours she can manage, and maintain her independence while living on less than $10,000 annually. The political rhetoric about able-bodied adults refusing to work crumbles when confronted with the reality of people like Kelley and Wallace—individuals who have worked, who want to work, but who face health challenges and caregiving responsibilities that make meeting arbitrary hourly requirements genuinely impossible. As these requirements take effect in 2027, millions of Americans will face Kelley’s fear and Wallace’s impossible choices, revealing whether policymakers’ commitment to fiscal responsibility will acknowledge the human cost of their decisions.