MISSOULA, Mont. — As congressional Republicans finalized Medicaid work requirements in President Donald Trump’s budget bill, one man who relies on that government-subsidized health coverage was trying to coax his old car to start after an eight-hour shift making sandwiches.
James asked that only his middle name be used to tell his story so that he wouldn’t lose health coverage or be accused of Medicaid fraud. He found his food service gig a few weeks into an addiction treatment program. The man in his late 30s said his boss “hasn’t been disappointed.”
“I’m a good worker,” he said with a grin.
James can get the prescription drugs that help him stabilize his life and hold down that job through Medicaid, the state-federal insurance program that covers people with low incomes or disabilities. Those drugs curb his desire for alcohol and treat long-standing conditions that exacerbate his addiction, including bipolar and insomnia disorders.
But he hasn’t qualified for the program in months, ever since his work hours increased and he received a raise of about $1 an hour. He exceeds his income eligibility limit of about $21,000 per year by roughly $50 a week.
James said that despite his raise, he’s struggling to cover routine expenses, such as keeping his car running and paying his phone bill. He said he can’t afford the care he needs even on the cheapest insurance plan available to him through the Affordable Care Act’s marketplace or through his job’s health insurance plan. Even paying $60 a month for his sleep medications — one of six prescriptions he takes daily — is too expensive.
“I only saw one option,” James said. “Fudge the numbers.”
James hasn’t reported his new income to the state. That puts him at odds with congressional Republicans who justified adding hurdles to Medicaid by claiming the system is rife with waste, fraud, and abuse. But James isn’t someone sitting on his couch playing video games, the type of person House Speaker Mike Johnson and other people said they would target as they sought work requirements.
Medicaid provides health coverage and long-term care to more than 70 million people in the United States. Those who study safety-net systems say it’s extremely rare for enrollees to commit fraud to tap into that coverage. In fact, research shows swaths of eligible people aren’t enrolled in Medicaid, likely because the system is so confusing. And nearly two-thirds of people on Medicaid in 2023 had jobs, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.
Those transitioning off Medicaid may qualify for other subsidized or low-priced health plans through the Affordable Care Act’s marketplace. But, as in James’ case, such plans can have gaps in what care is covered, and more comprehensive private plans may be too expensive. So James and an unknown number of other people find themselves caught between working too much to qualify for Medicaid but earning too little to pay for their own health care.
James considers himself to be a patriot and said that people shouldn’t “use government funding to just be lazy.” He agrees with the Republican argument that, if able, people should work if they receive Medicaid. Hiding his hours on the job from the government bothers him, especially since he feels he must lie to access the medical care that enables him to work.
“I don’t want to be a fraud. I don’t want to die,” James said. “Those shouldn’t be the only two options.”
On July 4, Trump signed into law the major tax and spending bill that makes it harder for low-income workers to get Medicaid. That includes requiring beneficiaries to work or go to school and adding paperwork to prove every six months they meet a minimum number of hours on the job.
“It’s going to hurt people, whether they’re playing by the rules or not,” said Ben Sommers, a health economist at Harvard University. “We see this vilification of mostly very hard-working people who are really struggling and are benefiting from a program that helps them stay alive.”
James said he initially declined his raise because he worried about losing Medicaid. He had previously been kicked off the coverage about a month into his rehab program after finding work. To stay in the sober-living program he otherwise couldn’t afford, James said, he dropped just enough hours at work to requalify for Medicaid and then soon picked up hours again. If he didn’t earn more, he said, he had no chance of saving enough money to find housing after graduating from the treatment program.
“They’ll give you a bone if you stay in the mud,” James said. “But you have to stay there.”
That problem — becoming just successful enough to suddenly lose Medicaid — is common. It’s called a benefit cliff, said Pamela Herd, who researches government aid at the University of Michigan.
“It just doesn’t make any sense that someone gets a dollar pay raise and all of a sudden they lose all access to their health insurance,” Herd said.
She said a partial fix exists called continuous eligibility, which guarantees an individual’s Medicaid coverage for a specific period, such as a year or longer. The goal is to give people time to adjust when they do earn more money. Continuous eligibility also helps maintain coverage for low-income workers with unpredictable hours and whose pay changes month to month.
But Congress has moved in the other direction. Under the new law, policymakers limited windows of eligibility for able-bodied adults to every six months. That will put more people on the program’s eligibility cliff, Herd said, in which they must decide between losing access to coverage or dropping hours at work.
“It is going to be a nightmare,” Herd said.
Those federal changes will be especially difficult for people with chronic conditions, such as James in Montana.
Not that long ago, James wouldn’t have been breaking the rules to access Medicaid because his state had 12-month continuous eligibility. But in 2023, Montana began requiring enrollees to report any change in their income within 10 days.
James is proud of how far he’s come. About a year ago, his body was breaking down. He couldn’t hold a spoon to eat breakfast without whiskey — his hands shook too hard. He had alcohol-induced seizures. He said his memories from his unhealthiest times come in flashes: being put on a stretcher, the face of a worried landlord, ambulance lights in the background.
James recently graduated from his treatment program. He’s staying with a relative to save money as he and his girlfriend try to find an affordable place to rent — though even with Medicaid, finding housing feels like a stretch to him. He’s taking classes part-time to become a licensed addiction counselor. His dream is to help others survive addiction, and he also sees that career as a way out of poverty.
To James, all his progress rides on keeping Medicaid a bit longer.
“Every time I get a piece of mail, I am terrified that I’m gonna open it up and it’s gonna say I don’t have Medicaid anymore,” he said. “I’m constantly in fear that it’s gonna go away.”
As of mid-July, officials hadn’t noticed the extra $50 he makes each week.
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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