Medicaid work rule leaves homeless people in the cold
New federal Medicaid work requirements, due to take effect in January 2027, will require millions of beneficiaries to prove they are working, volunteering or studying to keep their coverage — but homelessness was left off the list of exemptions, despite several states asking for it to be included. Advocates warn this could strip healthcare from hundreds of thousands of homeless people, many of whom face chronic illness, disability or addiction that makes steady employment and paperwork compliance extremely difficult, at a time when US homelessness has already risen sharply over the past decade.
Around 746,000 homeless Americans are expected to be affected, with 55% of people served by the roughly 300 Health Care for the Homeless programmes nationally already relying on Medicaid. Montana, Arkansas and Nebraska have begun implementing the rules, with Montana set to start removing non-compliant enrollees from October 2026 after giving people a 30-day window to prove they qualify for an exemption such as disability, pregnancy, being over 65 or Native American status. Case workers say the process assumes a stability many homeless people simply don't have; as one Montana case manager put it, "you can't really worry about getting paperwork done when you don't know where you're eating today." Nationally, the requirements are projected to push the number of uninsured people up by more than five million by 2034.
In short
- New Medicaid work rules exclude homelessness as a valid exemption
- About 746,000 homeless Americans risk losing coverage
- Montana starts removing non-compliant enrollees from October 2026
Steelman: both sides, in good faith
The strongest fair case each way — we don't pick a winner.
The case for
Supporters of the work requirements argue that activity-based incentives are essential for encouraging self-sufficiency and maintaining programme accountability. They contend that clear, verifiable exemptions based on specific conditions like disability, age and pregnancy provide a more administratively sound framework than broad housing-status exemptions, which may be temporary for some individuals. Moreover, they argue that work, volunteering or study requirements can themselves serve as pathways toward employment and housing stability.
The case against
Advocates argue that homeless people face formidable barriers to work compliance: no stable address, unreliable contact, and difficulty maintaining employment whilst managing chronic illness, mental health conditions or addiction. They contend that removing healthcare creates a destructive cycle where health deteriorates, employment becomes impossible, and homelessness deepens. Crucially, they argue that healthcare access itself may be necessary for achieving the stability required for employment, making the exemption fundamentally important.
Explained simply
Medicaid is a US public health insurance programme for people with low incomes and certain health needs. Many people experiencing homelessness rely on it for treatment, including care for long-term illness, disability and addiction.
Under the new federal rules, many adults covered by Medicaid will have to show that they are working, volunteering or studying to keep their insurance. Some groups, including people with disabilities and those over 65, are exempt, but homelessness itself is not listed as a reason for exemption.
The rules matter because keeping coverage may depend on meeting requirements and providing paperwork, which can be difficult without a stable home or reliable access to documents. Losing Medicaid could make it harder for homeless people to get healthcare, while increasing the number of people in the US without insurance.