In two years, the One Big Beautiful Bill passed by Republicans in Washington will require millions of low-income Americans to work, study or meet similar requirements to keep their health insurance.

Supporters say that will put more people to work and help shore up the program's finances. But in Arkansas and Georgia, the two states that tried such a requirement, the result has been a loss of coverage without a complementary increase in employment, studies show.

Can New Jersey do better? Kevin De Liban, litigation director for the nonprofit group Legal Aid of Arkansas, said that will require avoiding the technical glitches, confusing reporting systems and administrative hurdles that tripped up enrollees in his state.

"The core issue was the avalanche of paperwork," said De Liban, who led a federal lawsuit that overturned Arkansas' work requirement in 2019. "First, there was mass confusion. In many states, Medicaid isn’t even called Medicaid, so people often didn’t know they had it, or what kind they had, or whether the work requirements applied to their specific plan."

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The new law mandates that many adult Medicaid recipients — typically those ages 19 to 64 who are not pregnant or formally deemed disabled — must log at least 80 hours per month in work, job training, education, caregiving or other qualifying activities. The mandate is expected to roll out nationwide by January 2027, after the midterm elections.

Arkansas' version, launched in 2018 under President Donald Trump's first administration, provides a case study of how things could play out. Within five months of implementation, more than 18,000 of 67,000 eligible enrollees were dropped from Medicaid coverage.

Most were removed not because they had failed to abide by the new requirements but because they failed to report their activities on time, De Liban said.

An analysis by the nonpartisan Congressional Budget Office estimated that the One Big, Beautiful Bill Act could lead to coverage losses for 11.8 million people over the next decade. The CBO cited both changes in eligibility rules and funding in the legislation, as well as the potential impact of work requirements.

Making the case for Medicaid reforms

Republicans say the bill strengthens Medicaid by rooting out wasteful spending and ensuring the program remains sustainable for seniors, children, people with disabilities and other vulnerable groups.

U.S. Rep. Tom Kean Jr. voted for the Medicaid work requirements in the One Big Beautiful Bill, saying they were part of "common-sense reforms."

The bill is "the single strongest Medicaid package in our nation’s history" and "protects the needs of its intended beneficiaries," U.S. Rep. Tom Kean Jr., R-Westfield, declared on social media. "Our package makes common-sense reforms to root out waste, fraud, and abuse, so we can support and preserve the programs that thousands of New Jerseyans rely on."

Work requirements are a necessity, supporters say, because Medicaid's rolls have swollen since the passage of the Affordable Care Act in 2010. The program now covers 83 million people and costs about $870 billion annually.

"It is critical for Medicaid enrollees to have a stake in the taxpayer-subsidized benefits they receive," said Brian Blase, president of the Paragon Institute, a health care researcher that says it promotes market-based policies. "Work opens the door to independence, enabling individuals to support themselves without government assistance and to access private health coverage."

Studies show coverage losses, not work gains

Still, multiple studies have found that work requirements mostly led to coverage losses, not job gains, in Arkansas and Georgia. In Arkansas’ case, the people who lost insurance mainly did so due to missed paperwork. There was no increase in employment, according to research by the Urban Institute.

In Georgia, currently the only state with a work requirement, enrollment gains have been far below projections under the new rules — about 6,500 enrollees compared with a five-year target of 64,000. Most of the program's more than $40 million cost has gone to administration and consultants, not health care, said the Kaiser Family Foundation, a Washington group that studies health care policy.

Medicaid is jointly funded by state and federal governments and administered on the ground by states, meaning it will be up to New Jersey officials to implement the new work requirements. The Republican candidate in this year's governor's race, former state Assemblyman Jack Ciattarelli, didn't respond to a message asking about the Medicaid changes. His Democratic opponent, U.S. Rep. Mikie Sherrill, D-Montclair, noted that she opposed the bill.

"This bill adds red tape and bureaucracy that will make it harder to get care," Sherrill said in an email. "Some organizations are already anticipating a significant increase in administrative costs, even as funding is shrinking. We know these changes will kick people with disabilities off Medicaid, which is one of the many reasons I voted against this horrible bill.”

Advice for New Jersey

Avoiding coverage losses will require states to adopt more enrollee-friendly reporting systems, said De Liban, the Arkansas attorney.

"States can take steps to minimize coverage loss, though it’s important to understand that some eligible people will lose coverage no matter what — that was the clear lesson from Arkansas," he said.

"States should broadly define exemptions and automatically apply them when possible, so people don’t have to navigate paperwork" he added. "For those who do need to report, states should accept self-attestations and make the process simple."

Kevin De Liban, director of Advocacy at Legal Aid of Arkansas, lead the challenge that overturned the state’s Medicaid work requirements after more than 18,000 people lost coverage.

In an interview, De Liban offered further insights into what it looked like on the ground when work requirements were enacted in Arkansas and how other states might handle them.

Q: Who was affected most by the Arkansas Medicaid work requirement?

De Liban: People who were working but didn’t have stable jobs. People who had mental health conditions. People with disabilities. People who were caring for others. People who didn’t speak English or who had low literacy. All those folks were disproportionately affected.

Q: You’ve said many people technically qualified for exemptions. Why did they lose coverage anyway?

De Liban: They’d get confusing letters — sometimes one message one week, and then a completely different one the next. When they tried to call the state for clarification, they’d often be on hold for hours, and even if they got through, the information wasn’t always helpful.

The paperwork itself could be 10 pages long. People had to verify they were meeting the requirements, and in Arkansas, the only way to do that was through an online portal. That system required clicking through 10 to 20 screens — all with small fonts and unclear instructions.

You had to have login information, which had to be updated periodically or you'd get locked out. Even if someone successfully reported one month, they might not realize they had to do it again the next month. Some people had exemptions, but those expired after two or three months — and they had to keep track of all that.

The portal shut down at 9 p.m. every night. It didn’t work on smartphones. If you didn’t have internet or a computer, you couldn’t comply. We heard from people who were trying to report from public libraries, who were confused by the portal, or locked out.

Q: Was there a clear explanation of the new rules?

De Liban: The notices were incomprehensible. I’ve had legal training and still had a hard time understanding them. We had advocates and caseworkers trying to walk people through it — and they couldn’t make sense of it, either.

Q: What’s your response to those who say this was about preventing fraud?

De Liban: That narrative is a myth. The real fraud is designing a system that you know people won’t be able to navigate, then blaming them when they fail.

There’s almost no fraud on the part of Medicaid recipients in this country. Multiple studies have shown that. This whole "waste, fraud and abuse" idea is completely bogus when applied to people receiving Medicaid. There’s essentially none of that happening among recipients.

Second, this framing — especially as it's being used by Republicans — is meant to mislead. It denies the reality that Medicaid helps people be in the best shape they can be, given their circumstances. It allows them to work, take care of others, go to school, and do all the other things we all consider part of a decent life.

Q: What’s your advice to New Jersey as it prepares to implement the federal work requirements?

De Liban: Outreach is also critical — but it must be smart and strategic. In Arkansas, people were confused by texts and calls that felt like scams, even when they were from the state. Trust and clarity are essential.

States must also optimize their “ex parte” renewal systems — where they use existing data to automatically renew eligibility — to prevent unnecessary terminations. And they should be cautious when contracting with tech vendors like Deloitte or Maximus, ensuring systems work and contracts allow for fixes without huge costs.

Finally, states should collect and publish data on coverage losses and engage advocates early to help shape policies and reduce harm.

This article originally appeared on NorthJersey.com: Medicaid work requirements cut coverage for thousands in other states. Can NJ do better?