La mujer de 59 años, que vive en Harrisburg, Carolina del Norte, cerró el año pasado su escuela de artes circenses sin fines de lucro porque ya no veía lo suficientemente bien como para estar al día con todo el papeleo administrativo. Luego trabajó un tiempo haciendo masas en una pizzería. Ahora clasifica materiales reciclables, como latas y botellas, en un lugar de conciertos local. Es su principal fuente de ingresos, pero el trabajo no es durante todo el año.

“Este lugar me conoce, y este lugar me quiere”, dijo Kelley sobre su empleador. “Aquí no tengo que explicar por qué no puedo leer”.

Kelley vive en una casa rodante y sobrevive con menos de $10.000 al año. Dice que eso es posible, en parte, gracias a su cobertura de salud de Medicaid, que le cubre medicamentos para la artritis y la ansiedad, y le permite ir al doctor para controlar su hipertensión.

Pero le preocupa perder esa cobertura el año que viene, cuando entren en vigencia nuevas reglas que exigirán a millones de personas como ella trabajar, hacer voluntariado, ir a la escuela o realizar otras actividades que califiquen durante al menos 80 horas al mes.

“Ahora mismo tengo miedo”, dijo.

Antes de que se promulgaran los cambios para acceder a esta cobertura, legisladores republicanos sugirieron que hombres jóvenes y desempleados estaban abusando del programa gubernamental de salud que ofrece cobertura médica a millones de personas con bajos ingresos o con alguna discapacidad.

Medicaid no está pensado para “hombres de 29 años sentados en el sofá jugando videojuegos”, dijo Mike Johnson, presidente de la Cámara de Representantes, a CNN.

Pero en realidad, los adultos de entre 50 y 64 años, especialmente las mujeres, son quienes probablemente resulten más afectados por las nuevas reglas, según explicó Jennifer Tolbert, subdirectora del Programa sobre Medicaid y Personas sin Seguro de KFF, una organización sin fines de lucro de información sobre salud de la cual KFF Health News forma parte.

Para Kelley y otras personas, los requisitos laborales crearán obstáculos para mantener su cobertura, explicó Tolbert. Muchos podrían perder Medicaid, poniendo en riesgo su salud física y financiera.

A partir de enero de 2027, unos 20 millones de estadounidenses de bajos ingresos en 42 estados y el Distrito de Columbia tendrán que cumplir con los requisitos de actividad para obtener o conservar esta cobertura.

Alabama, Florida, Kansas, Mississippi, Carolina del Sur, Tennessee, Texas y Wyoming no ampliaron sus programas de Medicaid para cubrir a más adultos de bajos ingresos bajo la Ley de Cuidado de Salud a Bajo Precio (ACA), por lo que no tendrán que implementar las reglas de trabajo.

La no partidista Oficina de Presupuesto del Congreso, prevé que las reglas de trabajo resulten en al menos 5 millones de personas menos bajo Medicaid en la próxima década.

Según críticos, estas reglas son el principal factor de pérdida de cobertura dentro de la ley presupuestaria republicana, la cual recorta cerca de $1.000 millones para compensar reducciones de impuestos que benefician principalmente a personas con mayores ingresos y para aumentar la seguridad fronteriza.

“Estamos hablando de ahorrar dinero a costa de vidas humanas”, dijo Jane Tavares, investigadora en gerontología de la Universidad de Massachusetts en Boston. “El requisito de trabajo es solo una herramienta para lograr eso”.

Andrew Nixon, vocero del Departamento de Salud y Servicios Humanos, dijo que exigir a los “adultos sin discapacidades” que trabajen garantiza la “sostenibilidad a largo plazo” de Medicaid, mientras protege a las personas más vulnerables.

Las personas con discapacidades, quienes cuidan a familiares, personas embarazadas o en posparto, veteranos con discapacidades totales y otras personas que enfrentan dificultades médicas o personales están exentas de la regla de trabajo, indicó Nixon a KFF Health News.

La expansión de Medicaid ha sido un salvavidas para adultos de mediana edad que, de otro modo, no tendrían seguro médico, según investigadores de la Universidad Georgetown. Medicaid cubre a 1 de cada 5 estadounidenses de entre 50 y 64 años, dándoles acceso a atención médica hasta que califican para Medicare a los 65 años.

Entre las mujeres beneficiarias de Medicaid, las que tienen entre 50 y 64 años enfrentan más desafíos para conservar su cobertura que las más jóvenes, y suelen tener una mayor necesidad de servicios de salud, explicó Tolbert.

Estas mujeres de mediana edad tienen menos probabilidades de trabajar el número requerido de horas porque muchas son cuidadoras familiares o tienen problemas de salud que limitan su capacidad para trabajar, agregó.

Tavares y otros investigadores hallaron que solo el 8% de la población total de Medicaid que se considera “apta para trabajar” no trabaja. Este grupo está compuesto en su mayoría por mujeres muy pobres que han salido de la fuerza laboral para convertirse en cuidadoras. Entre ellas, 1 de cada 4 tiene 50 años o más.

“No son adultos jóvenes saludables simplemente perdiendo el tiempo”, escribieron los investigadores.

Además, dificultar el acceso a la cobertura de Medicaid “podría en realidad dificultar que estas personas trabajen”, ya que sus problemas de salud no recibirían tratamiento, advirtió Tolbert. De todas formas, si este grupo pierde la cobertura, sus condiciones crónicas igual necesitarán atención, señaló.

Muchos adultos empiezan a tener problemas de salud antes de ser elegibles para Medicare.

Si las personas mayores no tienen recursos para tratar sus problemas de salud antes de los 65 años, llegarán más enfermas a Medicare, lo que podría generar mayores costos para ese programa, apuntaron expertos en políticas de salud.

Muchas personas de entre 50 y principios de los 60 años ya no trabajan porque son cuidadoras de tiempo completo de hijos o familiares mayores, explicaron defensores, quienes se refieren a este grupo como “la generación sándwich”.

La ley presupuestaria republicana permite que algunos cuidadores queden exentos de las reglas de trabajo de Medicaid, pero las excepciones son “muy limitadas”, dijo Nicole Jorwic, directora de programas del grupo Caring Across Generations.

Le preocupa que personas que deberían calificar para una exención queden fuera por errores o complicaciones.

“Vamos a ver a más cuidadores familiares enfermándose, dejando de atender su propia salud y a más familias enfrentando crisis”, dijo Jorwic.

Paula Wallace, de 63 años, residente de Chidester, Arkansas, dijo que trabajó la mayor parte de su vida adulta y ahora dedica sus días a cuidar a su esposo, quien tiene cirrosis avanzada.

Después de años sin seguro, recientemente obtuvo cobertura gracias a la expansión de Medicaid en su estado, lo que significa que tendrá que cumplir con los nuevos requisitos laborales para conservarla. Pero le cuesta imaginar cómo podrá hacerlo.

“Como soy su única cuidadora, no puedo salir a trabajar fuera de casa”, dijo.

Su esposo recibe beneficios del Seguro por Incapacidad del Seguro Social, explicó, y la ley dice que ella debería quedar exenta de los requisitos de trabajo como cuidadora de tiempo completo de una persona con discapacidad.

Pero las autoridades federales aún no han emitido instrucciones específicas sobre cómo definir esa exención. Y la experiencia de Arkansas y Georgia —los únicos estados que han implementado programas de trabajo en Medicaid— muestra que muchas personas beneficiarias tienen dificultades para navegar sistemas de beneficios complejos.

“Estoy muy preocupada”, dijo Wallace.

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The 59-year-old, who lives in Harrisburg, North Carolina, closed her nonprofit circus arts school last year because she could no longer see well enough to complete paperwork. She then worked making dough at a pizza shop for a bit. Currently, she sorts recyclable materials, including cans and bottles, at a local concert venue. It is her main source of income ― but the work isn’t year-round.

“This place knows me, and this place loves me,” Kelley said of her employer. “I don’t have to explain to this place why I can’t read.”

Kelley, who lives in a camper, survives on less than $10,000 a year. She says that’s possible, in part, because of her Medicaid health coverage, which pays for arthritis and anxiety medications and has enabled doctor visits to manage high blood pressure.

But she worries about losing that coverage next year, when rules take effect requiring millions of people like Kelley to work, volunteer, attend school, or perform other qualifying activities for at least 80 hours a month.

“I’m scared right now,” she said.

Before the coverage changes were signed into law, Republican lawmakers suggested that young, unemployed men were taking advantage of the government health insurance program that provides coverage to millions of low-income or disabled people. Medicaid is not intended for “29-year-old males sitting on their couches playing video games,” House Speaker Mike Johnson told CNN.

But, in reality, adults ages 50 to 64, particularly women, are likely to be hit hard by the new rules, said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes KFF Health News. For Kelley and others, the work requirements will create barriers to keeping their coverage, Tolbert said. Many could lose Medicaid as a result, putting their physical and financial health at risk.

Starting next January, some 20 million low-income Americans in 42 states and Washington, D.C., will need to meet the activity requirements to gain or keep Medicaid health coverage.

Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming didn’t expand their Medicaid programs to cover additional low-income adults under the Affordable Care Act, so they won’t have to implement the work rules.

The nonpartisan Congressional Budget Office predicts the work rules will result in at least 5 million fewer people with Medicaid coverage over the next decade. Work rules are the largest driver of coverage losses in the GOP budget law, which slashes nearly $1 trillion to offset the costs of tax breaks that mainly benefit the rich and increase border security, critics say.

“We’re talking about saving money at the expense of people’s lives,” said Jane Tavares, a gerontology researcher at the University of Massachusetts Boston. “The work requirement is just a tool to do that.”

Department of Health and Human Services spokesperson Andrew Nixon said requiring “able-bodied adults” to work ensures Medicaid’s “long-term sustainability” while safeguarding it for the vulnerable. Exempt are people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship, Nixon told KFF Health News.

Medicaid expansion has provided a lifeline for middle-aged adults who otherwise would lack insurance, according to Georgetown University researchers. Medicaid covers 1 in 5 Americans ages 50 to 64, giving them access to health coverage before they qualify for Medicare at age 65.

Among women on Medicaid, those ages 50 through 64 are more likely to face challenges keeping their coverage than their younger female peers and are likely to have a greater need for health care services, Tolbert said.

These middle-aged women are less likely to be working the required number of hours because many serve as family caregivers or have illnesses that limit their ability to work, Tolbert said.

Tavares and other researchers found that just 8% of the total Medicaid population is considered “able-bodied” and not working. This group consists largely of women who are very poor and have left the workforce to become caretakers. Among this group, 1 in 4 are 50 or older.

“They are not healthy young adults just hanging out,” the researchers stated.

Plus, making it harder for people to maintain Medicaid coverage “may actually undermine their ability to work” because their health problems go untreated, Tolbert said. Regardless, if this group loses coverage, their chronic health conditions will still need to be managed, she said.

Adults often start wrestling with health issues before they’re eligible for Medicare.

If older adults don’t have the means to pay to address health issues before age 65, they’ll ultimately be sicker when they qualify for Medicare, costing the program more money, health policy researchers said.

Many adults in their 50s or early 60s are no longer working because they’re full-time caregivers for children or older family members, said caregiver advocates, who refer to people in the group as “the sandwich generation.”

The GOP budget law does allow some caregivers to be exempted from the Medicaid work rules, but the carve-outs are “very narrow,” said Nicole Jorwic, chief program officer for the group Caring Across Generations.

She worries that people who should qualify for an exemption will fall through the cracks.

“You’re going to see family caregivers getting sicker, continuing to forgo their own care, and then you're going to see more and more families in crisis situations,” Jorwic said.

Paula Wallace, 63, of Chidester, Arkansas, said she worked most of her adult life and now spends her days helping her husband manage his advanced cirrhosis.

After years of being uninsured, she recently gained coverage through her state’s Medicaid expansion, which means she’ll have to comply with the new work requirements to keep it. But she’s having a hard time seeing how that will be possible.

“With me being his only caregiver, I can’t go out and work away from home,” she said.

Wallace’s husband receives Social Security Disability Insurance, she said, and the law says she should be exempt from the work rules as a full-time caregiver for someone with a disability.

But federal officials have yet to issue specific guidance on how to define that exemption. And experience from Arkansas and Georgia ― the only states to have run Medicaid work programs ― shows that many enrollees struggle to navigate complicated benefits systems.

“I’m very concerned,” Wallace said.

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El residente de Austin, de 20 años, calificó el año pasado para recibir beneficios federales de alimentos porque salió del sistema de cuidado temporal (foster care, en inglés) de Texas, al que ingresó cuando era bebé.

El Programa de Asistencia Nutricional Suplementaria —conocido como SNAP, por sus siglas en inglés, o cupones de alimentos— ayuda a alimentar a 42 millones de personas con bajos ingresos en el país. Ahora, debido a cambios incluidos en la ley que los republicanos llaman One Big Beautiful Bill Act, Santillan-Garcia pronto podría tener que demostrar a las autoridades que está trabajando para conservar este beneficio.

Contó que perdió su último empleo por faltar al trabajo para ir al doctor para tratarse infecciones estomacales recurrentes. No tiene auto y ha solicitado empleo en supermercados, Walmart, Dollar General, “en cualquier lugar que se te ocurra” al que pueda llegar caminando o en bicicleta.

“Ningún trabajo me ha contratado”.

Según la nueva ley federal de presupuesto, más personas deben demostrar que están trabajando, haciendo voluntariado o estudiando para ser elegibles para SNAP.

Quienes no entreguen la documentación a tiempo corren el riesgo de perder la ayuda alimentaria por hasta tres años.

Al principio, se instruyó a los estados que comenzaran a contar “faltas” de los participantes a partir del 1 de noviembre, el mismo día en que millones de personas vieron suspenderse sus beneficios de SNAP por la negativa de la administración de Donald Trump a financiar el programa durante el cierre del gobierno.

Sin embargo, autoridades federales dieron marcha atrás a mitad de ese mes y dieron a los estados hasta diciembre para aplicar las nuevas reglas.

La ley también limita aún más cuándo los estados y condados con alto desempleo pueden eximir a los beneficiarios de estos requisitos. Pero una batalla legal sobre esa disposición ha generado que los plazos para cumplir con las nuevas normas varíen según el lugar donde vive la persona, incluso dentro del mismo estado en algunos casos.

El Departamento de Agricultura de Estados Unidos (USDA, por sus siglas en inglés) no respondió a una lista detallada de preguntas sobre cómo se implementarán las nuevas reglas de SNAP, y la Casa Blanca tampoco respondió a un pedido de comentarios sobre si estas reglas podrían dejar fuera del programa a personas que dependen de él.

La ley sí extendió exenciones para muchos integrantes de pueblos nativos americanos.

Aun así, los estados deben cumplir con las nuevas reglas o enfrentar sanciones que podrían obligarlos a cubrir una parte mayor del costo del programa, que el año pasado fue de aproximadamente $100.000 millones.

El presidente Trump firmó esta enorme ley presupuestaria, junto con los nuevos requisitos de SNAP, el 4 de julio. Según Chloe Green, subdirectora de la Asociación Estadounidense de Servicios Humanos Públicos (American Public Human Services Association), que asesora a los estados en programas federales, los estados inicialmente estimaron que necesitarían al menos 12 meses para aplicar cambios de tal magnitud.

Según la ley, las personas “capaces de trabajar” que están sujetas a requisitos laborales pueden perder el acceso a los beneficios por tres años si pasan tres meses sin presentar documentación que demuestra sus horas trabajadas.

Dependiendo de cuándo los estados apliquen las reglas, muchas personas podrían comenzar a ser excluidas del programa a principios del próximo año, dijo Lauren Bauer, investigadora en estudios económicos del centro de análisis Brookings Institution. Se espera que los cambios dejen al menos a 2,4 millones de personas fuera de SNAP durante la próxima década, según la Oficina de Presupuesto del Congreso.

“Es muy difícil trabajar si tienes hambre”, sentenció Bauer.

Muchos adultos beneficiarios de SNAP menores de 55 años ya tenían que cumplir con requisitos de trabajo antes de que se promulgara la ley presupuestaria.

Ahora, por primera vez, los que tengan entre 55 y 64 años, y los padres cuyos hijos tengan 14 años o más deben documentar al menos 80 horas mensuales de trabajo o de otras actividades válidas.

La nueva ley también elimina exenciones que desde 2023 se aplicaban a veteranos, personas sin vivienda y jóvenes que salieron del sistema de cuidado temporal, como Santillan-Garcia.

Políticos republicanos han dicho que estas nuevas reglas forman parte de un esfuerzo más amplio para eliminar el despilfarro, el fraude y el abuso en los programas de asistencia pública.

La secretaria de Agricultura, Brooke Rollins, dijo en noviembre que, además de aplicar la ley, requerirá que millones de personas vuelvan a solicitar los beneficios para reducir el fraude, aunque no dio más detalles. En una entrevista con Newsmax, Rollins afirmó que quiere asegurarse de que los beneficios de SNAP lleguen solo a quienes son “vulnerables” y “no pueden sobrevivir sin ellos”.

Green explicó que los estados están obligados a notificar a las personas que estarán sujetas a cambios en sus beneficios antes de que se los corten. Algunos estados han anunciado los cambios en sus sitios web o por correo, pero muchos no están dando suficiente tiempo para que los beneficiarios se pongan al día.

Defensores contra el hambre temen que los cambios, y la confusión que generan, aumenten el número de personas que enfrentan inseguridad alimentaria. Este año, los bancos de alimentos han reportado cifras récord de personas en busca de ayuda.

Incluso cuando cumplen con los requisitos laborales, muchas personas enfrentan dificultades para subir documentos y hacer que los estados procesen sus beneficios a través de sistemas saturados.

En una encuesta del Urban Institute, alrededor de 1 de cada 8 adultos dijo haber perdido los beneficios alimentarios por problemas al entregar la documentación. Algunos fueron dados de baja por errores del estado o por falta de personal.

Pat Scott, trabajadora comunitaria del Centro de Asistencia de Recursos Beaverhead, en la zona rural de Dillon, en Montana, es la única persona en al menos una hora de distancia conduciendo que ayuda a la población a acceder a asistencia pública, incluidos adultos mayores sin transporte confiable. Pero el centro solo abre una vez por semana, y Scott afirma que ha visto a personas perder la cobertura por problemas con el portal estatal en internet.

Jon Ebelt, vocero del Departamento de Salud de Montana, dijo que el estado trabaja continuamente para mejorar sus programas. Agregó que, si bien algunas reglas han cambiado, ya existe un sistema para reportar el cumplimiento de los requisitos laborales.

En Missoula, Montana, Jill Bonny, directora del albergue Poverello Center, explicó que sus clientes sin techo ya enfrentan grandes desafíos para solicitar ayuda: con frecuencia pierden sus documentos en medio del reto diario de cargar con todas sus pertenencias.

Bonny dijo que también le preocupa que los cambios federales puedan llevar a más personas mayores a quedarse sin hogar si pierden los beneficios de SNAP y tienen que elegir entre pagar la renta o comprar comida.

En Estados Unidos, las personas de 50 años o más son el grupo con mayor crecimiento dentro de la población sin vivienda, según datos federales.

Sharon Cornu, directora ejecutiva del St. Mary’s Center, una organización que apoya a adultos mayores sin hogar en Oakland, California, afirmó que las nuevas reglas están generando desconfianza. “Esto no es normal. No estamos jugando con las reglas de siempre”, dijo Cornu sobre los cambios federales. “Es una medida punitiva y malintencionada”.

A principios de noviembre, un juez federal en Rhode Island ordenó al gobierno de Trump entregar los pagos completos de SNAP durante el cierre del gobierno, que terminó el 12 de noviembre.

Ese mismo juez intentó frenar algunos de los nuevos requisitos laborales. Ordenó al gobierno respetar los acuerdos existentes que eximen del requisito de trabajo a ciertas personas en algunos estados y condados hasta que finalicen dichos acuerdos. En total, 28 estados y el Distrito de Columbia tenían estas exenciones, con fechas de finalización distintas.

Para complicar aún más la situación, algunos estados, como Nuevo México, tienen exenciones que hacen que personas en diferentes condados deban cumplir las reglas en distintos momentos.

Green explicó que si los estados no documentan adecuadamente el estatus laboral de los beneficiarios de SNAP, se les forzará a pagar después. Según la nueva ley, por primera vez los estados deben cubrir una parte del costo de los alimentos, y el monto dependerá de qué tan bien calculen los beneficios.

Durante el cierredel gobierno, cuando nadie recibió beneficios de SNAP, Santillan-Garcia y su novia dependieron de tarjetas de regalo de supermercados que les dio una organización sin fines de lucro para alimentar al bebé de su novia. Para comer ellos, recurrieron a un banco de alimentos, aunque muchos productos, como los lácteos, le hacen daño a Santillan-Garcia.

Le preocupa que en febrero vuelva a estar en la misma situación cuando tenga que renovar sus beneficios —ya sin la exención para jóvenes que salieron del sistema de cuidado temporal—. Las autoridades de Texas aún no le informan qué deberá hacer para seguir recibiendo SNAP.

Santillan-Garcia dijo que reza para que, si no logra encontrar trabajo, pueda encontrar otra forma de seguir cumpliendo los requisitos y mantener sus beneficios.

“Probablemente me los van a quitar”, dijo.

Lo que debes saber

Los cambios en SNAP eliminaron las exenciones a los requisitos laborales para:

• Personas de entre 55 y 64 años
• Cuidadores de menores de 14 años en adelante
• Veteranos
• Personas sin vivienda
• Jóvenes de hasta 24 años que salieron del sistema de cuidado temporal

Qué deben hacer los beneficiarios de SNAP

• Consultar con organizaciones de asistencia pública para saber cuándo entran en vigencia las nuevas reglas en su región. Es posible que las revisen al momento de recertificar, pero podrían pedirle cumplir con los requisitos laborales mensuales mucho antes.
• Informar a su estado si está a cargo de un menor de 14 años que vive en su hogar; está embarazada; estudia al menos medio tiempo; asiste a un programa de tratamiento de alcohol o drogas; tiene una condición física o mental que le impide trabajar; es una persona indígena; o cuida a un miembro del hogar incapacitado. Si cumple con alguno de estos criterios, podría seguir estando exento.

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The Supplemental Nutrition Assistance Program — commonly referred to as food stamps, or SNAP — helps feed 42 million low-income people in the United States. Now, because of changes included in the One Big Beautiful Bill Act, to keep his food benefits Santillan-Garcia might soon have to prove to officials that he’s working.

He said he lost his last job for taking time off to go to the doctor for recurrent stomach infections. He doesn’t have a car and said he has applied to a grocery store, Walmart, Dollar General, “any place you can think of” that he could walk or ride his bike to.

“No job has hired me.”

Under the new federal budget law, to be eligible for SNAP benefits, more people are required to show that they are working, volunteering, or studying. Those who don’t file paperwork in time risk losing food aid for up to three years. States were initially instructed to start counting strikes against participants on Nov. 1, the same day that millions of people saw their SNAP benefits dry up because of the Trump administration’s refusal to fund the program during the government shutdown. But federal officials backtracked partway through the month, instead giving states until December to enforce the new rules.

The new law further limits when states and counties with high unemployment can waive recipients from requirements. But a legal battle over that provision means that the deadline for people to comply with the new rules varies depending on where recipients live, even within a state in some cases.

The U.S. Department of Agriculture did not respond to a detailed list of questions about how the new rules around SNAP will be implemented, and the White House did not respond to a request for comment about whether the rules could kick off people who rely on the program. The law did extend exemptions to many Native Americans.

Still, states must comply with new rules or accrue penalties that could force them to pay a bigger share of the program’s cost, which was about $100 billion last year.

President Donald Trump signed the massive budget bill, along with the new SNAP rules, into law on July 4. States initially predicted they would need at least 12 months to implement such significant changes, said Chloe Green, an assistant director at the American Public Human Services Association who advises states on federal programs.

Under the law, “able-bodied” people subject to work requirements can lose access to benefits for three years if they go three months without documenting working hours.

Depending on when states implement the rules, many people could start being dropped from SNAP early next year, said Lauren Bauer, a fellow in economic studies at the Brookings Institution, a policy think tank. The changes are expected to knock at least 2.4 million people off SNAP within the next decade, according to the Congressional Budget Office.

“It’s really hard to work if you are hungry,” Bauer said.

Many adult SNAP recipients under 55 already needed to meet work requirements before the One Big Beautiful Bill Act became law. Now, for the first time, adults ages 55 to 64 and parents whose children are all 14 or older must document 80 hours of work or other qualifying activities per month. The new law also removes exemptions for veterans, homeless people, and former foster care youths, like Santillan-Garcia, that had been in place since 2023.

Republican policymakers said the new rules are part of a broader effort to eliminate waste, fraud, and abuse in public assistance programs.

Agriculture Secretary Brooke Rollins said in November that in addition to the law, she will require millions to reapply for benefits to curb fraud, though she did not provide more details. Rollins told Newsmax that she wants to ensure that SNAP benefits are going only to those who “are vulnerable” and “can’t survive without it.”

States are required to notify people that they are subject to changes to their SNAP benefits before they’re cut off, Green said. Some states have announced the changes on websites or by mailing recipients, but many aren’t giving enrollees much time to comply.

Anti-hunger advocates fear the changes, and confusion about them, will increase the number of people in the U.S. experiencing hunger. Food pantries have reported record numbers of people seeking help this year.

Even when adhering to the work rules, people often report challenges uploading documents and getting their benefits processed by overwhelmed state systems. In a survey of SNAP participants, about 1 in 8 adults reported having lost food benefits because they had problems filing their paperwork, according to the Urban Institute. Some enrollees have been dropped from aid as a result of state errors and staffing shortfalls.

Pat Scott, a community health worker for the Beaverhead Resource Assistance Center in rural Dillon, Montana, is the only person within at least an hour’s drive who is helping people access public assistance, including seniors without reliable transportation. But the center is open only once a week, and Scott says she has seen people lose coverage because of problems with the state’s online portal.

Jon Ebelt, a spokesperson with the Montana health department, said the state is always working to improve its programs. He added that while some of the rules have changed, a system is already in place for reporting work requirements.

In Missoula, Montana, Jill Bonny, head of the Poverello Center, said the homeless shelter’s clients already struggle to apply for aid, because they often lose documentation amid the daily challenge of carrying everything they own. She said she’s also worried the federal changes could push more older people into homelessness if they lose SNAP benefits and are forced to pick between paying rent or buying food.

In the U.S., people 50 or older are the fastest-growing group experiencing homelessness, according to federal data.

Sharon Cornu is the executive director at St. Mary’s Center, which helps support homeless seniors in Oakland, California. She said the rule changes are sowing distrust. “This is not normal. We are not playing by the regular rules,” Cornu said, referring to the federal changes. “This is punitive and mean-spirited.”

In early November, a federal judge in Rhode Island ordered the Trump administration to deliver full SNAP payments during the government shutdown, which ended Nov. 12. That same judge sought to buffer some of the incoming work requirements. He ordered the government to respect existing agreements that waive work requirements in some states and counties until each agreement is set to end. In total, 28 states and the District of Columbia had such exemptions, with different end dates.

Adding to the confusion, some states, including New Mexico, have waivers that mean people in different counties will be subject to the rules at different times.

If states don’t accurately document SNAP enrollees’ work status, they will be forced to pay later on, Green said. Under the new law, states must cover a portion of the food costs for the first time — and the amount depends on how accurately they calculate benefits.

During the government shutdown, when no one received SNAP benefits, Santillan-Garcia and his girlfriend relied on grocery gift cards they received from a nonprofit to prioritize feeding his girlfriend’s baby. They went to a food pantry for themselves, even though many foods, including dairy, make Santillan-Garcia sick.

He’s worried that he’ll be in that position again in February when he must renew his benefits — without the exemption for former foster care youths. Texas officials have yet to inform him about what he will need to do to stay on SNAP.

Santillan-Garcia said he’s praying that, if he is unable to find a job, he can figure out another way to ensure he qualifies for SNAP long-term.

“They’ll probably take it away from me,” he said.

What You Should Know

Changes to SNAP removed work-requirement exemptions for:

• People ages 55 to 64.
• Caretakers of dependent children 14 or older
• Veterans
• People without housing
• People 24 or younger who aged out of foster care

What SNAP Participants Should Do:

• Check with public assistance organizations to find out when the new rules go into effect in your region. Your benefits may be checked at recertification, but you may be required to meet the monthly work reporting rules long before that.
• Let your state know if you’re responsible for a dependent child younger than 14 who lives in your home; pregnant; a student at least half the time; attending a drug or alcohol treatment program; physically or mentally unable to work; a Native American; or a caretaker of an incapacitated household member. If so, you may still be exempt.

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Brader, de 27 años y residente de Bloomington, Indiana, tiene un marcapasos y una enfermedad dolorosa en las articulaciones. Además, sufre una lesión en la columna que le fusionó las vértebras del cuello, lo que le impide girar la cabeza.

La agencia estatal de Medicaid considera a Brader como “médicamente frágil”, lo que le da acceso a un conjunto ampliado de beneficios, como terapia física.

Pero nuevas reglas federales exigirán que más de 18 millones de personas beneficiarias de Medicaid en todo el país demuestren, a partir de 2027, que trabajan, hacen voluntariado o estudian al menos 80 horas al mes para mantener su cobertura.

Brader está exenta mientras siga siendo considerada médicamente frágil.

Pero ante la falta de directrices claras a nivel federal, los estados deben llegar a un acuerdo sobre cómo definir la fragilidad médica, una decisión de gran impacto que podría hacer que muchas personas pierdan el acceso a Medicaid, según funcionarios estatales, defensores del consumidor y expertos en políticas de salud.

“Estoy aterrada”, dijo Brader. “Ya he luchado mucho para conseguir esta atención médica”.

Mucho en juego

La ley One Big Beautiful Bill Act del presidente Donald Trump recortará casi $1.000 billones de dólares a Medicaid a lo largo de la próxima década. Buena parte de esos ahorros proyectados provendrían de dejar de cubrir a quienes no califiquen bajo las nuevas reglas laborales.

Esos recortes ayudan a financiar otras prioridades del Partido Republicano, como más seguridad fronteriza y recortes de impuestos que benefician sobre todo a personas con altos ingresos.

Legisladores conservadores han argumentado que Medicaid —el programa de seguro médico del gobierno para personas de bajos ingresos o con discapacidades— ha crecido demasiado, especialmente tras su expansión a más personas adultas de bajos ingresos bajo la Ley de Cuidado de Salud a Bajo Precio (ACA, por sus siglas en inglés). También afirman que exigirles trabajar a los beneficiarios es una medida de sentido común.

La nueva ley fiscal y presupuestaria de Trump ofrece excepciones a varias personas que podrían tener dificultades para cumplir con las reglas laborales, incluyendo aquellas consideradas “médicamente frágiles”. La ley define ciertas condiciones como fragilidad médica, por ejemplo, ceguera, discapacidad y adicciones. Pero no incluye muchas otras.

En su lugar, la norma exime a quienes tengan una “condición médica seria o compleja”, un término cuya interpretación puede variar según el estado.

Funcionarios estatales señalan que necesitan más claridad para asegurar que las personas que no pueden trabajar por razones de salud mantengan su derecho a Medicaid. También les preocupa que, incluso con una definición clara, muchas personas enfrenten el reto burocrático de tener que probar constantemente  que son médicamente frágiles, lo cual es difícil si no se puede acceder a una atención médica adecuada.

“Hay mucho en juego”, dijo Kinda Serafi, socia de la firma consultora Manatt Health.

Los nuevos requisitos laborales afectarán a beneficiarios de Medicaid en 42 estados y en Washington, DC. Ocho estados —Alabama, Florida, Kansas, Mississippi, Carolina del Sur, Tennessee, Texas y Wyoming— no expandieron sus programas de Medicaid para incluir a más personas adultas de bajos ingresos, por lo que no tendrán que implementar estas reglas.

Según la Oficina de Presupuesto del Congreso (Congressional Budget Office), una entidad no partidista, se espera que estas reglas laborales de Medicaid sean el principal factor que provoque la pérdida de cobertura médica en la próxima década.

El 44% de las personas adultas cubiertas por los programas de Medicaid en estados que lo ampliaron tienen al menos una afección crónica, según KFF.

Un desafío para los estados

Las agencias estatales de Medicaid se apresuran a implementar las nuevas reglas con poca orientación del Departamento de Salud y Servicios Humanos de Estados Unidos (HHS, por sus siglas en inglés) que aún no ha emitido directrices específicas. Andrew Nixon, vocero de la agencia, dijo que la definición federal de “médicamente frágil” se aclarará el próximo año.

En última instancia, serán los estados los que tengan que decidir quién está lo suficientemente enfermo como para quedar exento de los requisitos laborales. Y no será fácil para el personal estatal ni para los sistemas informáticos hacer ese seguimiento.

Cada año, los sistemas estatales de elegibilidad evalúan a millones de personas solicitantes para determinar si califican para Medicaid y otros programas gubernamentales. Ahora, esos mismos sistemas también tendrán que verificar si personas nuevas o ya inscritas cumplen con los requisitos laborales.

Jessica Kahn, socia en la firma consultora McKinsey & Co., ha instado a los estados a comenzar desde ya a planear cómo adaptar sus sistemas para verificar el estatus laboral. Los estados pueden hacer “muchísimo” incluso sin esperar directrices federales, dijo Kahn —quien fue funcionaria federal de Medicaid— durante una reciente audiencia de asesoría sobre el programa. “El tiempo se acaba”.

Las personas encargadas de Medicaid a nivel estatal evalúan este reto.

“La fragilidad médica es algo muy complejo”, dijo Emma Sandoe, directora de Medicaid en Oregon, durante un panel reciente. Las condiciones que impiden trabajar, como los trastornos de salud mental, son difíciles de demostrar, explicó.

Un estado podría intentar usar información de los expedientes médicos de una persona, por ejemplo, para determinar si es médicamente frágil. Pero esa información puede no reflejar con claridad la salud de alguien, especialmente si no tiene acceso regular a servicios médicos.

Es una tarea difícil para sistemas de elegibilidad que históricamente no han tenido que revisar registros médicos para evaluar solicitudes, señaló Serafi, de Manatt Health.

“Esto es completamente nuevo para los sistemas de inscripción, y simplemente no están preparados”, añadió.

Grupos de cabildeo que representan a compañías privadas de seguros médicos que administran Medicaid en varios estados también han pedido a las autoridades federales que definan claramente qué significa ser médicamente frágil, para que se aplique de manera uniforme.

En una carta enviada el 3 de noviembre, las organizaciones Planes de Salud Medicaid de Estados Unidos (MHPA, en inglés) y la Asociación de Planes Afiliados a la Comunidad (ACAP, en inglés) recomendaron que se permita a las personas solicitantes calificar para la exención simplemente al indicar en su solicitud que tienen condiciones que las hacen médicamente frágiles. Según las dos organizaciones, implementar con éxito estas exenciones será “crucial” dada la “gravedad de los riesgos para la salud que implica perder cobertura” para estas poblaciones.

Algunos funcionarios estatales temen que haya consecuencias imprevistas por estas reglas laborales para personas con enfermedades crónicas.

Jennifer Strohecker, quien recientemente renunció como directora de Medicaid en Utah, reiteró la gravedad de este asunto, especialmente para personas con diabetes afiliadas a Medicaid.

Explicó que, si bien pueden llevar una vida funcional con insulina, eso podría cambiar si pierden la cobertura por no cumplir con los requisitos laborales.

Actualmente, el hecho de que alguien sea considerado médicamente frágil depende en gran medida del lugar donde viva.

Por ejemplo, en Arkansas, las personas deben indicar en sus solicitudes de Medicaid si tienen una discapacidad, son ciegas o necesitan ayuda para realizar actividades diarias.

Según Gavin Lesnick, vocero del Departamento de Servicios Humanos de Arkansas, aproximadamente el 6% de las 221.000 personas inscritas en el programa de expansión de Medicaid del estado se consideran médicamente frágiles.

En West Virginia, el estado acepta la designación de fragilidad médica cuando una persona la reporta por cuenta propia.

En Dakota del Norte, el proceso es más estricto. Quienes solicitan deben completar un cuestionario sobre su salud y presentar documentación adicional, como notas del historial médico y planes de tratamiento. Más de la mitad de las solicitudes fueron rechazadas el año pasado, según Mindy Michaels, vocera del Departamento de Salud y Servicios Humanos.

La Administración de Servicios Familiares y Sociales de Indiana, que gestiona Medicaid en ese estado, se negó a ofrecer entrevistas y dijo que no podía comentar sobre casos individuales, como el de Brader.

Brader teme que la burocracia adicional la haga perder otra vez su cobertura de Medicaid. Contó que en 2019 fue expulsada temporalmente del programa por no cumplir con las reglas laborales del estado, cuando Indiana determinó que su trabajo como estudiante no contaba como empleo.

“Siempre que he intentado recibir ayuda del estado de Indiana, ha sido una pesadilla burocrática”, dijo.

Mientras los estados esperan una guía federal, Kristi Putnam —miembro del conservador Instituto Cicero y ex secretaria del Departamento de Servicios Humanos de Arkansas— dijo que, incluso si un estado crea una lista extensa de condiciones que califican como fragilidad médica, siempre habrá que poner un límite.

“No se puede crear una política de exenciones que lo cubra todo”, afirmó.

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States depend heavily on federal funds to operate their food stamp programs, which help feed about 42 million people nationwide. But a new federal law has restructured the nation’s food assistance, requiring more people to work to qualify for aid and shifting more of the program’s cost onto states over the next decade. Meanwhile, many Americans are struggling to afford groceries, and state governments are straining to help them.

More than a year ago, for example, a federal judge ruled that Missouri’s food aid system was “overwhelmed,” had wrongly denied assistance to applicants, and had caused many to go hungry as a “direct result of the system’s inadequacy.” The judge, Douglas Harpool, ordered the state to fix the problems.

Despite the court order, not much has changed, according to a KFF Health News analysis of state performance metrics.

Missouri’s ongoing problems foreshadow the trouble that lies ahead for state food aid programs nationwide. Food assistance advocates have said Missouri is just one example of a nationwide problem in which strained state systems struggle to deliver timely aid. For example, low-income people in Alaska have faced chronic backlogs while the state has spent years trying to fix the problem.

Last year, then-U.S. Agriculture Secretary Tom Vilsack sent letters to 44 governors urging swifter application processing and greater accuracy in determining benefits.

The administrative snarls come on top of concerns about funding during the recent federal government shutdown. The Trump administration refused to use emergency funds to keep the food aid program running, and food benefits lapsed for millions of people, including in Missouri, on Nov. 1 as the shutdown dragged into its fifth week. Two federal judges ordered the Trump administration to tap emergency funds for the program.

The shutdown ended Nov. 12, and Missouri said its SNAP recipients began receiving their full benefits three days later. Meanwhile, as Thanksgiving approached, benefit delays were still being reported in some states.

Even after the shutdown, states will have to do more with fewer resources. Republicans’ One Big Beautiful Bill Act slashes billions in federal funding to the food aid program and pushes more of the administrative and financial burden to states.

The bill President Donald Trump signed in July axes $187 billion over the next decade from the Supplemental Nutrition Assistance Program, commonly referred to as food stamps, or SNAP. That represents a 20% cut, according to the Congressional Budget Office.

One of the most significant and immediate changes requires more people to work to qualify for aid. The change will cause at least 2.4 million Americans to lose aid, according to an analysis from the bipartisan Congressional Research Service. The analysis predicts many people will lose their benefits because the work requirements will make applying more difficult.

Expanding work requirements will harm some of the nation’s most vulnerable people, said Ed Bolen, who leads food aid strategies at the left-leaning Center on Budget and Policy Priorities.

But the conservative Foundation for Government Accountability, a group that has worked to advance similar policies in states, says the requirement is necessary to preserve assistance for the “truly needy.”

‘Undisputed’ Strains in Missouri

Some Missourians were already struggling before Trump signed the bill.

Kelly Thweatt, 64, said she received a notice in the mail that her food benefits had been cut back. She didn’t understand why, because her income hadn’t changed, she said recently outside a SNAP office 60 miles west of St. Louis.

After she pays for her spot at a mobile home park in Warrenton, she said, she’s left with about $300 each month from Social Security. The roughly $300 in SNAP benefits she had received every month kept her afloat.

Thweatt will be subject to the new federal work requirement because she’s not yet 65.

More than 150,000 Missourians are at risk of losing some amount of food aid because of the new work requirement, which went into effect Nov. 1.

For Thweatt, finding a job may prove difficult. She’s been out of the workforce for nearly 20 years.

Food aid provides a lifeline to more than 650,000 Missourians — that’s more than eight sold-out crowds at Arrowhead Stadium in Kansas City, where the NFL’s Chiefs play. The program helps feed 20% of Missouri’s children every month, according to the Missouri Foundation for Health, a nonprofit philanthropic organization. (The foundation provides financial support to KFF Health News.)

The recent federal changes will require more seniors, parents, veterans, homeless people, and former foster care youths to clear additional administrative hurdles to get food aid, according to the U.S. Department of Agriculture.

For years, thousands of Missourians have struggled to tap into food assistance, largely because applicants must complete an interview, over the phone or in person. But many Missourians can’t get through to a state staffer.

Applicants have spent hours waiting on hold or in line outside state offices, according to a lawsuit filed in 2022 in federal court. At times, so many people have been waiting on hold that the phone system started hanging up on people, the lawsuit says.

Some Missouri SNAP offices are staffed by only a single employee, according to Harpool’s May 2024 order, adding to the strain.

In a statement provided to KFF Health News, the Missouri Department of Social Services said that because demand varies by location, it may be appropriate to have a single staffer in some places.

In Warrenton, makeshift phone booths line the walls of the food aid office. People sit at a cubicle with a desk and use a phone to complete interviews with officials elsewhere. A sign sitting on the floor asks applicants to “please be patient with our progress” as the state works on technology improvements.

According to Harpool’s order, the “evidence is undisputed” that Missouri’s food aid system has “unacceptable wait times” and that thousands of calls “cannot be completed.” These problems put Missourians at risk of losing aid “each and every time” they apply for food benefits, the judge wrote. To stay in the program, most households need to periodically submit documents and complete interviews.

A KFF Health News analysis of Missouri SNAP reports showed the same problems persist more than a year later. In the 16 months after the judge’s order, nearly half of all the applications that were denied were rejected at least partly because no interview was completed, according to data the state submitted to the court as part of the order. That indicates the state’s system is failing the most vulnerable, the judge has said.

In an order released in May of this year, Harpool found that Missouri failed to show significant improvement and that its performance deteriorated by some measures. The state hadn’t documented adding a single staffer or investing any additional resources to process applications faster, Harpool wrote.

Missouri’s Department of Social Services said the state legislature has provided money to hire temporary workers in other areas, freeing up staff to process SNAP applications.

To complete the required interviews for food aid, the agency said, it makes multiple attempts to reach applicants once an application is received.

Katie Deabler, an attorney with National Center for Law and Economic Justice who represented Missourians in the case, said, “These are your neighbors, these are your kids’ classmates who are going hungry when the system doesn’t work.”

Trouble Ahead

Roughly 68% of the state’s food aid recipients are children, adults over 60, or people with a disability, according to the Missouri Foundation for Health. Many who can work already do.

Christine Woody, the food security policy manager with Empower Missouri, an organization working to eradicate poverty in the state, said Missouri lacks the money and the will to fix its food aid system.

Woody and other advocates fear the federal changes will erode the nation’s most powerful defense against hunger.

“For a state like Missouri that is already struggling to operate the program, these new rules couldn’t come at a worse time,” said Bolen, of the Center on Budget and Policy Priorities.

Missouri foreshadows the trouble that lies ahead for other states, he said. Like Missouri, many states are reluctant to fund their food aid programs. And now they’ll be forced to use state dollars to fill the gaps left by the federal cuts, which “sets states up to fail,” Bolen said.

Supporters of the changes see it differently. U.S. House Speaker Mike Johnson previously described the cost shift to states as “modest” and said it’s necessary to reduce fraud. States “don’t have enough skin in the game,” he said on CBS’ “Face the Nation” ahead of the budget bill’s passage.

Still, if states do not come up with the money to fill the gap, Bolen said, they’ll be left with two options: Make it harder for people to qualify for SNAP, or end the program entirely.

For Thweatt, the change comes at a particularly hard moment. A few months ago, she lost her life partner of three decades, leaving her reeling and struggling to afford the basics. She does not turn 65 until April, which means she’s subject to the expanded work requirement until then and may have to show she has a job to maintain the $220 in monthly food benefits she has left. The state will apply the work rules to her case when she’s up for renewal, state officials said. Thweatt’s car needs repairs and its license plates are set to expire, she said. She doesn’t have the money to address either problem.

She’s selling everything that she can, including an antique bedroom set, to afford necessities, she said.

“I can satisfy myself with a bag of chips per day,” Thweatt said. “So if that’s what I need to do, that’s what I need to do.”

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The 27-year-old resident of Bloomington, Indiana, has a pacemaker and a painful joint disease. She also has fused vertebrae in her neck from a spinal injury, preventing her from turning her head.

Indiana’s Medicaid agency currently considers Brader “medically frail,” giving her access to an expanded set of benefits, such as physical therapy.

New federal rules will require more than 18 million Medicaid enrollees nationwide to show they’re working, volunteering, or going to school for 80 hours a month starting in 2027 to keep their coverage. Brader is exempt as long as she’s deemed medically frail.

But lacking sufficient federal guidance, states are wrestling with how to define medical frailty — a consequential decision that could cut Medicaid coverage for many people, said state officials, consumer advocates, and health policy researchers.

“It’s terrifying,” Brader said. “I already have fought so hard to get my health care.”

‘Incredibly High’ Stakes

President Donald Trump’s One Big Beautiful Bill Act slashes nearly $1 trillion from Medicaid over the next decade, with much of the savings projected to come from no longer covering those who don’t qualify under the new work rules. Those spending cuts help offset the costs of GOP priorities, such as extra border security and tax cuts that mainly benefit the wealthy.

Conservative lawmakers have argued that Medicaid, the government health insurance program for people with low incomes or with disabilities, has grown too large and expensive, especially in the wake of its expansion to more low-income adults under the Affordable Care Act. They also say that requiring participants to work is common sense.

The work rules in Trump’s tax-and-spending law offer exemptions for several groups who might struggle to meet them, including people deemed “medically frail.” The law spells out certain “medically frail” conditions such as blindness, disability, and substance use disorder. But it does not list many others.

Instead, the law exempts those with a “serious or complex medical condition,” a term whose interpretation could vary by state.

State officials say they need more clarity to ensure that people who cannot work for health reasons retain rightful access to Medicaid. They also worry that, even with a clear definition, people will face the onerous task of having to regularly vouch for being medically frail, which is a challenge without reliable access to medical care.

“The stakes are incredibly high,” said Kinda Serafi, a partner at consulting firm Manatt Health.

The new work requirements will affect Medicaid recipients in 42 states and Washington, D.C. Eight states — Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming — did not expand their Medicaid programs to cover additional low-income adults, so they won’t have to implement the work rules.

The Medicaid work rules are expected to be the largest driver of health insurance coverage losses over the next decade, according to the nonpartisan Congressional Budget Office.

Forty-four percent of all adults covered by states’ expanded Medicaid programs have at least one chronic health condition, according to KFF.

A Challenge for States

State Medicaid agencies are scrambling to implement the rules with little direction from the U.S. Department of Health and Human Services, which has yet to issue specific guidance. Federal officials will clarify the “medically frail” definition next year, said Andrew Nixon, an agency spokesperson.

Ultimately, states will have to decide who is unhealthy enough to be exempt from work rules. And it won’t be easy for state workers and their computer systems to track.

Every year, state eligibility systems screen millions of applicants to check if they qualify for Medicaid and other government programs. Now, these same systems must screen applicants and existing enrollees to determine whether they meet the new work rules.

Jessica Kahn, a partner at consulting firm McKinsey & Co., has urged states to start planning how to adapt eligibility systems to verify work status. States can do a “tremendous amount” of work without direction from the federal government, said Kahn, a former federal Medicaid systems official, who spoke during a recent Medicaid advisory panel hearing. “Time is a-wasting already.”

State Medicaid directors are pondering the challenge.

“Medical frailty gets so complex,” Emma Sandoe, Oregon’s Medicaid director, said during a recent panel discussion. Conditions that can keep people from working, such as mental health disorders, can be hard to prove, she said.

A state might try to use data pulled from a person’s health records, for instance, to determine medical frailty. But information from a patient’s chart may not paint a clear picture of someone’s health, especially if they lack regular access to medical care.

It’s a tall order for eligibility systems that historically have not had to scrape medical records to screen applicants, said Serafi of Manatt Health.

“That is an incredibly new thing that eligibility enrollment systems are just not fluent in at all,” Serafi said.

Lobbying groups for the private health insurance companies that help run Medicaid in many states also have urged federal regulators to clearly define medical frailty so it can be applied uniformly.

In a Nov. 3 letter to federal officials, the Medicaid Health Plans of America and the Association for Community Affiliated Plans advocated for allowing enrollees to qualify for the exemption by saying on their applications that they have conditions that make them medically frail. Successfully implementing exemptions for the medically frail will be “crucial” given the “severe health risks of coverage loss for these populations,” the groups said.

Some state officials worry about unintended consequences of the work rules for people with chronic conditions.

Jennifer Strohecker, who recently resigned as Utah’s Medicaid director, reiterated the high stakes, especially for those with diabetes on Medicaid. They may be very healthy and functional with insulin, but if they fail to complete the work requirements, that may change, Strohecker said during a recent Medicaid advisory hearing.

Whether someone is deemed medically frail already depends heavily on where they live.

For example, in Arkansas, people indicate on their Medicaid applications that they’re disabled, blind, or need help with daily living activities.

Approximately 6% of the roughly 221,000 people enrolled in Arkansas’ Medicaid expansion program are deemed medically frail, according to Gavin Lesnick, a spokesperson for the Arkansas Department of Human Services.

In West Virginia, the state accepts a medical frailty designation when an applicant self-reports it.

The burden of proof is higher in North Dakota. Applicants there must answer a questionnaire about their health and submit additional documentation, which may include medical chart notes and treatment plans. More than half of applicants were denied last year, according to Health and Human Services Department spokesperson Mindy Michaels.

Indiana’s Family and Social Services Administration, which runs its Medicaid program, declined an interview and said it could not comment on individual cases, like Brader’s.

Brader worries the additional red tape will cause her to lose Medicaid again. She said she was temporarily kicked off the program in 2019 for failing to meet the state’s work rules when Indiana said her work-study job didn’t count as employment.

“Anytime I have tried to receive help from the state of Indiana, it has been a bureaucratic nightmare,” she said.

As states await federal guidance, Kristi Putnam, a senior fellow at the conservative Cicero Institute and former secretary of the Arkansas Department of Human Services, which oversees the state Medicaid program, said even if a state creates an extensive list of qualifying “medically frail” conditions, the line must be drawn somewhere.

“You can’t possibly create a policy for exemptions that will catch everything,” she said.

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Permanent changes to the Supplemental Nutrition Assistance Program are coming regardless of the outcome of at least two federal lawsuits that seek to prevent the government from cutting off November SNAP benefits. The lawsuits challenge the Trump administration’s refusal to release emergency funds to keep the program operating during the government shutdown.

A federal judge in Rhode Island ordered the government to use those funds to keep SNAP going. A Massachusetts judge in a separate lawsuit also said the government must use its food aid contingency funds to pay for SNAP, but gave the Trump administration until Nov. 3 to come up with a plan.

Amid that uncertainty, food banks across the U.S. braced for a surge in demand, with the possibility that millions of people will be cut off from the food program that helps them buy groceries.

On Oct. 28, a vanload of SpaghettiOs, tuna, and other groceries arrived at Gateway Food Pantry in Arnold, Missouri. It may be Gateway’s last shipment for a while. The food pantry south of St. Louis largely serves families with school-age children, but it has already exhausted its yearly food budget because of the surge in demand, said Executive Director Patrick McKelvey.

New Disabled South, a Georgia-based nonprofit that advocates for people with disabilities, announced that it was offering one-time payments of $100 to $250 to individuals and families who were expected to lose SNAP benefits in the 14 states it serves.

Less than 48 hours later, the nonprofit had received more than 16,000 requests totaling $3.6 million, largely from families, far more than the organization had funding for.

“It’s unreal,” co-founder Dom Kelly said.

The threat of a SNAP funding lapse is a preview of what’s to come when changes to the program that were included in the One Big Beautiful Bill Act that President Donald Trump signed in July take effect.

The domestic tax-and-spending law cuts $187 billion within the next decade from SNAP. That’s a nearly 20% decrease from current funding levels, according to the Congressional Budget Office.

The new rules shift many food and administrative costs to states, which may lead some to consider withdrawing from the program, which helped about 42 million people buy groceries last year. Separate from the new law, the administration is also pushing states to limit SNAP purchases by barring such things as candy and soda.

All that “puts us in uncharted territory for SNAP,” said Cindy Long, a former deputy undersecretary at the Department of Agriculture who is now a national adviser at the law firm Manatt, Phelps & Phillips.

The country’s first food stamps were issued at the end of the Great Depression, when the poverty-stricken population couldn’t afford farmers’ products. Today, instead of stamps, recipients use debit cards. But the program still buoys farmers and food retailers and prevents hunger during economic downturns.

The CBO estimates that about 3 million people will lose food assistance as a result of several provisions in the budget law, including applying work requirements to more people and shifting more costs to states. Trump administration leaders have backed the changes as a way to limit waste, to put more people to work, and to improve health.

This is the biggest cut to SNAP in its history, and it is coming against the backdrop of rising food prices and a fragile labor market.

The exact toll of the cuts will be difficult to measure, because the Trump administration ended an annual report that measures food insecurity.

Here are five big changes that are coming to SNAP and what they mean for Americans’ health:

1. Want food benefits? They will be harder to get.

Under the new law, people will have to file more paperwork to access SNAP benefits.

Many recipients are already required to work, volunteer, or participate in other eligible activities for 80 hours a month to get money on their benefit cards. The new law extends those requirements to previously exempted groups, including homeless people, veterans, and young people who were in foster care when they turned 18. The expanded work requirements also apply to parents with children 14 or older and adults ages 55 to 64.

Starting Nov. 1, if recipients fail to document each month that they meet the requirements, they will be limited to three months of SNAP benefits in a three-year period.

“That is draconian,” said Elaine Waxman, a senior fellow at the Urban Institute, a nonprofit research group. About 1 in 8 adults reported having lost SNAP benefits because they had problems filing their paperwork, according to a December Urban Institute survey.

Certain refugees, asylum-seekers, and other lawful immigrants are cut out of SNAP entirely under the new law.

2. States will have to chip in more money and resources.

The federal law drastically increases what each state will have to pay to keep the program.

Until now, states have needed to pay for only half the administrative costs and none of the food costs, with the rest covered by the federal government.

Under the new law, states are on the hook for 75% of the administrative costs and must cover a portion of the food costs. That amounts to an estimated median cost increase for states of more than 200%, according to a report by the Georgetown Center on Poverty and Inequality.

A KFF Health News analysis shows that a single funding shift related to the cost of food could put states on the hook for an additional $11 billion.

All states participate in the SNAP program, but they could opt out. In June, nearly two dozen Democratic governors wrote to congressional leaders warning that some states wouldn’t be able to come up with the money to continue the program.

“If states are forced to end their SNAP programs, hunger and poverty will increase, children and adults will get sicker, grocery stores in rural areas will struggle to stay open, people in agriculture and the food industry will lose jobs, and state and local economies will suffer,” the governors wrote.

3. Will the changes lead to more healthy eating?

The Trump administration, through its “Make America Healthy Again” platform, has made healthy eating a priority.

Health and Human Services Secretary Robert F. Kennedy Jr. has championed the restrictions on soda and candy purchases within the food aid program. To date, 12 states have received approval to limit what people can buy with SNAP dollars.

Federal officials previously blocked such restrictions, because they were difficult for states and stores to implement and they boost stigma around SNAP, according to a 2007 USDA report. In 2018, the first Trump administration rejected an effort from Maine to ban sugar-sweetened drinks and candy.

A store may decide that hassle isn’t worth participating in the program and drop out of it, leaving SNAP recipients fewer places to shop.

People who receive SNAP are no more likely to buy sweets or salty snacks than people who shop without the benefits, according to the USDA. Research shows that encouraging healthy food choices is more effective than regulating purchases.

When people have less money to spend on food, they often resort to cheaper, unhealthier alternatives that keep them sated longer rather than paying for more expensive food that is healthy and fresh but quick to perish.

4. How will SNAP cuts affect health?

Advocacy organizations working to end hunger in the nation say the cuts will have long-term health effects.

Research has found that kids in households with limited access to food are more likely to have a mental disorder. Similarly, food insecurity is linked to lower math and reading skills.

Working-age people with food insecurity are more likely to experience chronic disease. That long list includes high blood pressure, arthritis, diabetes, asthma, and chronic obstructive pulmonary disease.

Those health issues come with costs for individuals. Low-income adults who aren’t on SNAP spend on average $1,400 more a year on health care than those who are.

About 47 million people lived in households with limited or uncertain access to food in 2023.

5. What does this mean for the nation’s food supply chain?

SNAP spending directly boosts grocery stores, their suppliers, and the transportation and farming industries. Additionally, when low-income households have help accessing food, they’re more likely to spend money on other needs, such as prescriptions or car repairs. All that means that every dollar spent through SNAP generates at least $1.50 in economic activity, according to the USDA.

A report by associations representing convenience stores, grocers, and the food industry estimated it could cost grocers $1.6 billion to comply with the new SNAP restrictions.

Advocates warn stores may pass the costs on to shoppers, or they may close.

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The letters, dated Oct. 10, were sent to four companies and follow a KFF Health News investigation that exposed widespread issues in states using Deloitte-run systems to assess Medicaid eligibility for millions of people. Failures have resulted in the erroneous loss of health coverage and other vital safety-net benefits for low-income people. Malfunctions in those systems can cost millions and take years to fix.

As most states prepare to institute work requirements mandated by the tax and domestic spending law President Donald Trump signed in July, senators wrote it is each company’s responsibility to build functioning systems, “rather than to prioritize their bottom line.”

Democratic senators Ron Wyden of Oregon, Elizabeth Warren of Massachusetts, and Raphael Warnock of Georgia, as well as Sen. Bernie Sanders (I-Vt.), sent the letters to several companies the Centers for Medicare & Medicaid Services identified as eligibility system contractors: Deloitte, GDIT, Gainwell Technologies, and Conduent.

“They’re essentially health care middlemen that are in the business of red tape, and they profit when Americans don’t get health care,” Wyden, the top Democrat on the Senate Finance Committee, which oversees Medicaid, said in an interview.

“They’ve got a history of poor performance when it comes to determining eligibility or in helping Americans enroll in Medicaid,” Wyden said. “Without stronger oversight and real accountability, these contractors are just going to get a jumbo windfall for creating systems that actually harm Americans trying to get health care.”

Spokespeople for the four companies did not provide comments for this article.

As of June, 70.5 million people were enrolled in Medicaid, according to CMS.

A handful of states operate their own Medicaid eligibility and enrollment systems, but most rely on contractors to build and run them. KFF Health News found that Deloitte, a global consultancy that generated $70.5 billion in revenue in fiscal year 2025, dominates this slice of government business. Twenty-five states have awarded Deloitte contracts for eligibility systems. The agreements, in which the company commits to design, develop, implement, or operate state-owned systems, are worth at least $6 billion, dwarfing any of its competitors.

Kinda Serafi, a partner at Manatt Health, is advising states on how to reconfigure their systems to incorporate work requirements.

States are in a “major sprint” to make changes by 2027, she said, and they’re being “inundated” with pitches from vendors looking to secure contracts. It underscores the business opportunity these system changes represent for contractors.

“I think we have to really be vigilant to make sure that these vendors are implementing the requirements consistent with the law,” Serafi said.

Companies sign contracts with state governments, but the federal government pays the bulk of the cost. The federal government covers 90% of states’ costs to develop and implement state Medicaid eligibility systems and 75% of ongoing maintenance and operations expenses, according to federal regulations.

The Senate letters cite problems with Deloitte-run eligibility systems that KFF Health News identified. Among other issues, the Florida eligibility system erroneously cut benefits for new moms, and a problem in Kentucky prevented coverage applications from getting through online, which cost $522,455 and took 10 months to resolve.

“Unfortunately, these are just a few examples of third-party systems’ failure to serve their very function: to reliably and accurately determine an individual’s eligibility for Medicaid coverage and services,” the senators wrote.

The senators asked the companies to respond by Oct. 31 to their questions, such as whether companies’ contracts with states include financial incentives tying payment to the removal of Medicaid enrollees and whether the companies are penalized for coverage terminations made in error. The senators also demanded an accounting of the company’s lobbying expenditures for the past five years and protocols for making system changes.

By 2027, the Congressional Budget Office projected, based on an early version of the bill, 18.5 million Medicaid beneficiaries will have to work or complete other qualifying activities for 80 hours a month to keep their benefits, unless they qualify for an exemption. The CBO estimates that 5.3 million enrollees will lose coverage by 2034.

The new work requirements are just one of several federally mandated Medicaid changes that are forcing states to adapt their eligibility systems.

Medicaid work requirements have been plagued with problems in the few states where they’ve been tested. Medicaid enrollees have been frustrated in trying to navigate byzantine rules and glitchy technology. Work requirements have also come at great cost.

Georgia has not adopted the ACA Medicaid expansion, which has granted benefits to millions of adults earning up to 138% of the federal poverty level. Instead, the state offers benefits to some people earning up to the poverty line who can prove they’re working or participating in similar activities for 80 hours a month. Nearly 110,000 Georgians had applied to the state’s Georgia Pathways to Coverage program through May, but only 9,157 people were enrolled as of mid-August. Under typical ACA expansion rules, 336,000 adults would be eligible for coverage, according to KFF.

The Georgia program has cost $109 million, with $34 million spent on health benefits and more than $20 million allocated to marketing contracts, according to a KFF Health News analysis of state reports. Deloitte built Georgia’s eligibility system and is the primary consultant for the Pathways program.

Before Medicaid work requirements became federal law, Arizona also submitted a request to federal regulators to launch its own version that would apply to roughly 190,000 people.

The state’s application provided insight into the types of system changes states may soon need to make to manage the new federal work requirement.

Arizona Medicaid officials said they would gather information on enrollees’ work hours, training, and education. The state’s eligibility system, which is operated by Accenture, would also need to check whether someone is exempt.

States are in the early stages of determining changes they need to make to implement work requirements.

Tessa Outhyse, a spokesperson for the California Department of Health Care Services, said the state expects upgrades to be processed “through the existing contractual change order process.” State contracts with eligibility companies often set aside millions to cover the cost of changes, but systems may require upgrades beyond the agreed-upon work.

In Missouri, upgrades are expected to cost roughly $33 million, according to a state budget document.

The state has a contract with private company RedMane to handle some of its Medicaid eligibility processing. Missouri plans to hire an additional contractor to ensure it properly institutes Medicaid work requirements, according to Baylee Watts, a spokesperson for Missouri’s Department of Social Services.

Medicaid eligibility contractors “have a lot of leverage and expertise to influence contracts, to win contracts,” Wyden said. “They can do a lot more, to the value of what we’re giving them.”

KFF Health News senior correspondent Renuka Rayasam and correspondent Sam Whitehead contributed to this report.

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Health and Human Services Secretary Robert F. Kennedy Jr. said to applause that the legislation was just the start and that he wanted to prevent federal funding from paying for other unhealthy foods.

“We’re not going to do that overnight,” Kennedy said. “We’re going to do that in the next four years.”

Those words of caution proved prescient when Arizona’s Democratic governor, Katie Hobbs, vetoed the bill a week later. Nevertheless, state legislation to restrict what low-income people can buy using Supplemental Nutrition Assistance Program benefits is gaining momentum, boosted by Kennedy’s touting it as part of his “Make America Healthy Again” platform. At least 14 states have considered bills this year with similar SNAP restrictions on specific unhealthy foods such as candy, with Idaho and Utah passing such legislation as of mid-April.

Healthy food itself isn’t largely a partisan issue, and those who study nutrition tend to agree that reducing the amount of sugary food people eat is a good idea to avoid health consequences such as heart disease. But the question over the government’s role in deciding who can buy what has become political.

The organization largely behind SNAP restriction legislation is the Foundation for Government Accountability, a conservative policy think tank out of Florida, and its affiliated lobbying arm, which has used the name Opportunity Solutions Project.

FGA has worked for more than a decade to reshape the nation’s public assistance programs. That includes SNAP, which federal data shows helps an average of 42 million people afford food each month. It also advocates for ways to cut Medicaid, the federal-state program that connects 71 million people to subsidized health care, including efforts in Idaho and Montana this year.

FGA’s proposals often seek to limit who taps into that aid and the help they receive. Those backing the group’s mission say the goal is to save tax dollars and help people lift themselves out of poverty. Critics argue that FGA’s proposals are a backdoor way to cut off aid to people who need it and that making healthy food and health care more affordable is a better fix.

Now, FGA sees more room for change under the Trump administration and the Kennedy-led health department, calling 2025 a “window of opportunity for major reform,” according to its latest annual report.

A Vision for Limiting Government Benefits

Tarren Bragdon, a former Maine legislator, founded FGA in 2011 to promote policies to “free millions from government dependency and open the doors for them to chase their own American Dream,” he said in a statement on FGA’s website. The main foundation started out as a staff of three with about $60,000 in the bank. As of 2023, it had a budget of more than $15 million and a team of roughly 64, according to the latest available tax documents, and that’s not counting the lobbying arm.

The foundation got early funding from a grant from the State Policy Network, which has long backed right-leaning think tanks with ties to conservative activists including brothers Charles and David Koch.

FGA declined several interview requests for this article.

In recent years, the nonprofit helped draft a 2017 Mississippi law, the Jackson Free Press found, which intensified eligibility checks for public aid that made it more difficult for some applicants to qualify. It successfully pushed a 2023 effort in Idaho to impose work requirements for food benefits that health care advocates said led some recipients to lose access.

The same year, the group helped pass SNAP restrictions affecting eligibility in Iowa. Since those restrictions have taken effect, the Food Bank of Iowa has seen a record number of people show up at its pantries amid rising grocery prices and a scaling back of covid pandemic-era federal support, said Annette Hacker, a vice president at the nonprofit.

Part of the group’s strategy is to pass legislation state by state, with the idea that the crush of new laws will increase pressure on the federal government. For example, states can’t limit what food is purchased through SNAP without federal approval through a waiver process. And in the past, some of FGA’s efforts have stalled because states never got that approval.

Kennedy’s agenda now echoes some of FGA’s key messages, and he has said states can expect approval of their waivers. Meanwhile, congressional leaders are eyeing nationwide Medicaid cuts and work requirements, which FGA considers among its major issues. The foundation also has a connection working inside the administration: Its former policy director, Sam Adolphsen, was tapped to advise President Donald Trump on domestic matters.

“We’re excited to fight from Topeka to Washington, D.C., as opposed to Washington, D.C., to Topeka,” Roy Lenardson, FGA’s state government affairs director, told Kansas lawmakers in February when testifying in support of SNAP legislation there.

Shaping State Policies

In the states, FGA has become known as a conservative “thought leader,” said Brian Colby, vice president of public policy for Missouri Budget Project, a progressive nonprofit that provides analysis of state policy issues.

“Conservatives used to try to chop away at the federal budget,” Colby said. “These guys are doing it at the state level.”

In its 14 years, FGA has created a playbook to shape state policy discussions around public benefits behind the scenes. In Montana, retired Republican legislator Cary Smith, who worked with FGA, said not all of the think tank’s ideas split along party lines.

“They offer a buffet of options,” he said. “Their agenda is making government accountable; it’s in the name.”

He said besides drafting legislation, FGA provides talking points and data to help policymakers support their arguments. “They would go in and would say, ‘This is what Medicaid fraud is costing us,’” Smith said. “That would be the number you’d want to use in your bill.”

In January, FGA released a memo for states to “stop taxpayer-funded junk food.” In February, Stateline reported that Wyoming Republican state Rep. Jacob Wasserburger said the group asked him to sponsor a SNAP restriction bill. The state sponsor of similar legislation in Missouri has repeated at least one of FGA’s talking points, as reported by the Missouri Independent. In Arizona, Republican Rep. Leo Biasiucci, who sponsored the SNAP legislation there, told KFF Health News FGA was behind that bill as well.

Opponents of such bills argue the proposals are not as simple as they sound. Amid debate on a SNAP bill in Montana, Kiera Condon, with the Montana Food Bank Network, testified the legislation would force grocery store workers to sort through what counts as soda or candy, “which could result in retailers not participating in SNAP at all.”

State lawmakers tabled the Montana bill in April.

Montana legislators also easily passed a bill to extend the state’s Medicaid expansion program even after FGA began publishing a series of papers that asserted the program was “breaking” Montana’s budget. FGA had presented data saying most Montanans on the program don’t work, which state data refutes.

Ed Bolen, who leads food aid strategies at the left-leaning Center on Budget and Policy Priorities think tank, said FGA has a pattern of proposing technical changes to existing laws and “unworkable work requirements” that cause people to lose benefits.

After working with policymakers in Kansas for a decade, FGA helped pass legislation that limited how long people can access cash assistance, added work requirements to SNAP, and banned the state from spending federal or state funds to promote public aid. Many of those changes came through 2015 legislation known as the “HOPE Act” drafted by FGA, The Washington Post reported.

Analysis from Kansas Appleseed, an advocacy organization for low-income Kansans, found the SNAP caseload sharply declined after the bill was enacted because of the new hurdles, dropping from 140,000 households in January 2014 to 90,000 as of January 2020.

“It’s death by a thousand cuts,” said Karen Siebert, an adviser for Harvesters, a community food bank network in Kansas and Missouri. “Some of these FGA proposals are such complex policies, it’s hard to argue against and to explain the ripple effects.”

In 2024, the foundation produced more than two dozen videos featuring state politicians from across the nation touting the organization’s goals and dozens of research papers arguing public benefits are wrecking state budgets. FGA also has its own polling team to produce data out of the states it’s working to influence.

The organization released a list of 14 states it labeled as “redder and better” places to exert more influence. That included Idaho, where the group has four registered lobbyists in the state Capitol.

In 2023, FGA helped present and successfully lobby for legislation there to require people receiving food aid to work at least 80 hours a month. The organization called the resulting law “landmark welfare reform” years in the making.

And this year, Idaho lawmakers passed more requirements for people enrolled in Medicaid who can work. FGA staffers worked with one of the co-sponsors of the legislation on a similar bill last year that failed, then again this year. A compromise bill passed with FGA’s backing, marking another victory for the foundation.

David Lehman, a lobbyist for the Idaho Association of Community Providers, which represents health organizations that have opposed FGA bills, said Idaho illustrates how FGA works with sympathetic lawmakers in conservative states to gain more ground.

“They’re pushing an already rolling rock downhill,” he 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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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