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.