2026年4月15日 美国东部时间凌晨5:00 / KFF健康新闻
未来数年数百万申请医疗补助的民众，将必须证明自己已工作、上学或从事志愿活动至少1个月，才能通过该政府项目获得或保留健康保险。
但部分州的共和党议员认为，这些新规则——即去年7月特朗普总统签署的共和党《一项宏伟法案》中的相关内容——力度还不够。
印第安纳州率先采取行动，出台新法律要求申请者证明自己已连续3个月工作或参与类似活动，才能获得福利。
与此同时，美国其他许多州的民众只需证明自己工作了1个月，这是特朗普签署的税收与国内支出法案中最宽松的选项。该法案允许各州自行决定要求1、2或3个月的工作经历。
和印第安纳州一样，爱达荷州的共和党议员也通过了3个月工作要求的法案，该州州长已于4月10日签署法案使之生效。
这些举措，以及亚利桑那州、密苏里州和肯塔基州的类似行动，旨在限制各州执行联邦法律的灵活性。
“通常情况下，州议员不会介入这类决策，”美国癌症协会宣传部门高级官员露西·达诺说道。
无党派的国会预算办公室估计，将有1850万成年人受新规则约束，这些规则将在42个州和哥伦比亚特区实施。在印第安纳州，工作要求将覆盖该州约33%的医疗补助参保人群。这些规则通常不适用于儿童、65岁及以上人群、残疾人或患有严重健康问题的人群。
通常情况下，州行政部门而非议员会详细说明如何遵守新的联邦标准，且他们通常会寻求联邦监管机构的指导。但医疗保险和医疗补助服务中心的官员尚未告知各州如何全面落实这项全面预算法案的诸多要求，导致州议员不得不介入。
共和党州长迈克·布劳恩于3月4日签署了印第安纳州的法案，使其成为首个将医疗补助工作要求设定为3个月的州——这也是联邦法律允许的最长时限。
州共和党参议员克里斯·加滕于1月提出一项法案，称该法案旨在“协调”州法律与新的联邦医疗补助规则。他还将该法案宣传为打击公共项目中“浪费、欺诈和滥用”的一种方式。
当不符合资格的人员参保时，就会“抢走真正有需要的脆弱印第安纳州民众的救助机会”，加滕在1月的委员会听证会上说道。
州民主党参议员法迪·卡杜拉在听证会上表达了质疑，并质疑该立法的必要性。卡杜拉要求印第安纳州家庭与社会服务管理局局长米奇·鲁布提供该州不符合资格却参保的人数估算。
“我认为会非常少，”鲁布回应道，“但永远不会是零。”
听完鲁布的回答后，卡杜拉表示没有证据表明印第安纳州存在普遍的此类问题。他指责共和党以浪费、欺诈和滥用为借口，剥夺脆弱印第安纳州民众的健康福利和食品援助。
加滕随后称卡杜拉的指控是对该法案的“根本性错误描述”。
共和党人士表示，实施这些限制有助于保护医疗补助项目的可持续性。
“我们相信为最脆弱人群提供安全网，而非为选择不工作的健全成年人提供吊床，”加滕说道，“通过收紧这些限制，我们确保安全网保持可持续性。”
根据印第安纳州无党派立法服务局的分析，加滕的法案将导致印第安纳州的医疗补助参保人数减少。
印第安纳正义项目是一家专注于健康、住房和粮食不安全问题的无党派法律维权组织，其执行董事亚当·穆勒表示，医疗补助有助于民众保持健康，从而能够继续工作。
穆勒担心民众会难以证明自己的工作经历，尤其是从事非传统工作的人群。
“如果目的是让人们参与工作，1个月的要求就足够了，”穆勒说道。
他最终担心该法案会伤害最需要援助的印第安纳州民众。“他们会被官僚主义的障碍绊倒。”
预算与政策优先中心的一项分析预测，工作要求将为参保设置新障碍，各州如何执行这些规则将“显著影响失去保险的人数”。这家左翼智库发现，州政策决策将决定“负担的严苛程度”，选择更短的回溯期“将让更多人能够参保”。
多个州的议员都考虑过设置相关限制。同一右翼游说团体——政府问责基金会——在亚利桑那州、印第安纳州和密苏里州为这些措施作证支持。
在密苏里州，该基金会的说客詹姆斯·哈里斯表示，该举措旨在“让人们摆脱依赖，重新找回工作的尊严和自豪感”。
密苏里州众议员达林·查普尔曾提出要求3个月回溯期的法案，效仿印第安纳州的做法。但他所提案的最新版本法案仅要求申请者在参保前证明自己工作了1个月。
共和党人查普尔表示，他的倡议将鼓励“工作心态”。
密苏里州哥伦比亚市一家小面包店的店主安娜·迈耶表示，这项政策的言下之意是她和其他医疗补助参保者很懒惰。“我从15岁起就一直在工作，”她说道，“现在我43岁了。”
迈耶表达了反对意见，称她之前曾遇到过向州医疗补助机构提交信息的困难。她担心新的申报要求会让她和其他人面临失去保险的风险，即便他们符合工作规则。
她患有纤维肌痛，这是一种会增加全身疼痛敏感度的慢性病，她还有食物过敏问题。医疗补助帮助支付药物和就医费用，让她保持健康并能够继续工作。
“我工作非常努力，”迈耶说道。
在圣路易斯，妇产科医生杰西卡·诺顿在阿菲尼亚医疗诊所接诊了许多医疗补助患者。她说，即便密苏里州为产后符合资格的女性提供一整年的医疗补助覆盖，她们仍难以保住保险。她的一些患者在产后六周的复查时，就莫名被取消了保险覆盖。她担心新工作要求带来的繁文缛节会让人们更难保住保险，尽管孕妇和新妈妈本应获得豁免。
诺顿批评议员们向脆弱患者传递了错误信号。他们在说，“哦，实际上医疗保健是一种特权，你必须通过努力才能获得，”她说道。
杰西卡·诺顿是圣路易斯阿菲尼亚医疗诊所的妇产科医生，接诊了许多持有医疗补助保险的患者。她担心女性会成为新医疗补助工作要求的主要受害者，因为她们往往承担无报酬的护理工作。萨曼莎·利斯/KFF健康新闻
根据KFF的数据，近三分之二年龄在19至64岁之间的医疗补助参保成年人已经在工作。KFF发现，其余未工作的成年人之所以没有工作，是因为他们已退休、在担任照顾者或身体过于虚弱。
一些州不仅设定了最严格的要求，还排除了联邦规则中可选的宽松条款。
例如，各州可以增设工作规则豁免条款，比如允许人们申请“短期困难豁免”，旨在为因健康状况无法工作的人群提供持续的医疗补助覆盖。
密苏里州议员正在寻求一项宪法修正案，禁止该州提供此类可选豁免。但患者维权人士警告称，这些限制会在最需要保障的时候伤害该州的脆弱居民，尤其是密苏里州的农村癌症患者。
美国癌症协会宣传部门的说客艾米丽·卡尔默在1月的听证会上作证称，密苏里州的农村患者往往需要前往堪萨斯城或圣路易斯接受治疗，这会打乱他们的工作能力。联邦法律针对这种情况规定了特定的豁免条款。
但密苏里州将不再提供这项短期困难豁免。
“时间对癌症患者或癌症幸存者来说至关重要，”卡尔默说道。
KFF健康新闻是一家专注卫生问题深度报道的全国性新闻编辑部，也是KFF的核心运营项目之一——KFF是独立的卫生政策研究、民意调查和新闻资讯来源机构。
New federal Medicaid rules require 1 month of work. Some states demand more.
April 15, 2026 5:00 AM EDT / KFF Health News
Millions of people who apply for Medicaid in the coming years will have to prove they’ve been working, going to school, or volunteering for at least one month before they can gain or retain health insurance through the government program.
But Republican lawmakers in some states think the new rules — part of the GOP’s One Big Beautiful Bill Act, signed last July by President Trump — don’t go far enough.
Indiana is leading that charge, with a new law that requires applicants to prove they’ve been working or participating in a similar activity for three consecutive months to get benefits.
Meanwhile, residents in many other states will have to show they’ve been working just one month, the least cumbersome option under Mr. Trump’s signature tax-and-domestic-spending law. It instructs states to decide whether to require one, two, or three months of work history.
Like Indiana, Republican Idaho lawmakers also approved a three-month requirement, and the state’s governor signed the bill into law on April 10.
The efforts, along with similar moves in Arizona, Missouri, and Kentucky, are aimed at restricting flexibility to implement the federal law at the state level.
“Normally, you would not see state legislators weighing in on these decisions,” said Lucy Dagneau, a senior official with the American Cancer Society’s advocacy arm.
The nonpartisan Congressional Budget Office estimated 18.5 million adults will be subject to the new rules, which will be enforced across 42 states and the District of Columbia. In Indiana, work rules will target about 33% of the state’s Medicaid population. The rules generally wouldn’t apply to children, people 65 or older, or people with disabilities or serious health issues.
Typically, state administrators — not lawmakers — detail how they plan to comply with new federal standards, and they often look to federal regulators for guidance. But officials at the Centers for Medicare & Medicaid Services have yet to tell states how to comply with many aspects of the sweeping budget law, leaving state lawmakers to intervene.
Gov. Mike Braun, a Republican, signed the Indiana bill into law on March 4, making his state the first to set the Medicaid work requirement at three months — the longest period allowed under the federal law.
Republican state Sen. Chris Garten introduced a bill in January, saying it was needed to “align” state law with the new federal Medicaid rules. He also pitched the bill as a way to crack down on “waste, fraud, and abuse” in public programs.
When ineligible people get enrolled, it robs “the truly vulnerable Hoosier who actually needs the help,” Garten said during a January committee hearing.
Democratic state Sen. Fady Qaddoura expressed skepticism during the hearing and questioned the necessity of the legislation. Qaddoura asked Indiana Family and Social Services Administration Secretary Mitch Roob to provide an estimate of the number of ineligible people who enrolled in Medicaid in the state.
“I think very few,” Roob replied. “It’ll never be none.”
After hearing Roob’s answer, Qaddoura said there is no evidence of a widespread problem in Indiana. He accused Republicans of using waste, fraud, and abuse as justification to deny health benefits and food aid to vulnerable Hoosiers.
Garten later called Qaddoura’s accusation a “fundamental mischaracterization” of the bill.
Republicans have said imposing these limits protects the Medicaid program’s longevity.
“We believe in a safety net for our most vulnerable, not a hammock for able-bodied adults that choose not to work,” Garten said. “By tightening these screws, we ensure that our safety net remains sustainable.”
Indiana’s Medicaid enrollment is expected to decrease because of Garten’s legislation, according to an analysis from Indiana’s nonpartisan Legislative Services Agency.
Medicaid helps keep people healthy, so they can continue to work, said Adam Mueller, executive director of the Indiana Justice Project, a nonpartisan legal advocacy organization focusing on health, housing, and food insecurity.
Mueller worries that people will struggle to prove their work history, especially those with nontraditional jobs.
“If the point is to get people engaged, the one month would do it,” Mueller said.
Ultimately, he fears the law will harm Hoosiers with the greatest need for assistance. “They’re going to get tripped up by the bureaucratic hurdles.”
An analysis by the Center on Budget and Policy Priorities predicted that work rules will impose new barriers to coverage and that how states choose to implement the rules will “significantly affect the number of people who lose coverage.” State policy decisions will determine just “how intense the burden is,” the left-leaning think tank found, and opting for a shorter look-back period “will enable more people to enroll.”
Lawmakers in multiple states considered limits. And the same right-leaning lobbying group, the Foundation for Government Accountability, testified in favor of these measures in Arizona, Indiana, and Missouri.
In Missouri, FGA lobbyist James Harris said the measure intends to “move people from dependency and give them back that dignity and pride of work.”
Missouri state Rep. Darin Chappell proposed requiring a three-month look-back period like the measure in Indiana. But the latest version of the bill he sponsored would require applicants to show they were working for only one month before enrolling.
Chappell, a Republican, said his initiative would encourage a “working mindset.”
Anna Meyer, owner of a small bakery in Columbia, Missouri, said the implication is that she and others on Medicaid are lazy. “I have been working since I was 15 years old,” she said. “I’m 43 now.”
Meyer, who voiced her opposition, said she previously had problems submitting information to the state Medicaid agency. She fears new reporting requirements will put her and others at risk of losing coverage, even if they meet the work rule.
She has fibromyalgia, a chronic condition that increases overall sensitivity to pain. She also has food allergies. Medicaid helps pay for medications and doctor visits that keep her healthy and allow her to keep working.
“I work very hard,” Meyer said.
In St. Louis, Jessica Norton, an OB-GYN, treats many Medicaid patients at an Affinia Healthcare clinic. She said they struggle to remain insured even though Missouri extends a full year of Medicaid coverage to eligible women after they give birth. Some of her patients are inexplicably kicked off that coverage by the time of their checkups six weeks after birth. She fears red tape from the new work requirements will make it harder to hang on to insurance, even though pregnant women and new mothers are supposed to be exempt.
Norton criticized lawmakers for the message this policy sends to vulnerable patients. They are saying, “Oh, actually, health care is a privilege, and you have to earn it,” she said.
Jessica Norton is an OB-GYN who treats many patients with Medicaid coverage at an Affinia Healthcare clinic in St. Louis. She fears women will bear the brunt of new Medicaid work requirements because they’re often performing unpaid labor. Samantha Liss/KFF Health News
Nearly two-thirds of adults ages 19 to 64 on Medicaid already work, according to KFF. The reason many of the remaining adults on Medicaid are not working is that they are retired, serving as a caregiver, or too sick, KFF has found.
Some states are not only setting the strictest requirements but also blocking out the optional leniency built into the federal rules.
For example, states may adopt additional exemptions from work rules, such as allowing people to claim a “short-term hardship,” designed to provide continued Medicaid coverage to people with medical conditions that prevent them from working.
Missouri lawmakers are seeking a constitutional amendment to bar their state from offering such optional exemptions. But patient advocates warn these limits would harm the state’s vulnerable residents when they need coverage the most, particularly Missouri’s rural cancer patients.
Often, rural Missouri patients must travel to Kansas City or St. Louis for treatment, disrupting their ability to work, Emily Kalmer, a lobbyist for the American Cancer Society’s advocacy arm, testified at the January hearing. Recognizing this, the federal law provides certain exemptions for this kind of scenario.
But this short-term hardship exemption would be off the table in Missouri.
Time is “very important in the life of a cancer patient or a cancer survivor,” Kalmer said.
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.