In the heart of Missoula, Montana, Tywon Pugh, a 46-year-old man with a history of seizures, finds himself in a precarious situation. After losing his job and his wife within a year, Pugh became homeless and now faces the challenge of meeting new Medicaid work requirements to keep his healthcare coverage.
Pugh is not alone. Across the United States, homeless individuals are grappling with the implications of these new rules, which require them to prove they are working, volunteering, or going to school to maintain their Medicaid benefits. The federal government finalized these regulations in the spring of 2026, giving states until January 2027 to implement them. However, some states, like Montana, Arkansas, and Nebraska, have already begun enforcing these requirements.
Understanding the New Medicaid Work Requirements
The new Medicaid work requirements exempt certain groups of people, such as those with disabilities, those older than 64, pregnant people, and Native Americans. However, being homeless is not considered a medical condition and does not qualify for an automatic exemption. This leaves many homeless individuals, like Pugh, in a difficult position as they struggle to meet the new criteria.
According to the Department of Housing and Urban Development, homelessness in the U.S. increased by 27% from 2013 to 2026. Last year, about 746,000 people were homeless. Many of these individuals qualified for Medicaid, but the number of enrollees who are homeless is difficult to measure. In 2026, 55% of patients who received medical or behavioral health services through one of the nation’s roughly 300 Health Care for the Homeless programs were enrolled in Medicaid.
The Challenges of Meeting the Work Requirements
For homeless individuals, meeting the work requirements can be a significant challenge. Many struggle with health issues, substance abuse, and mental health conditions that make it difficult to find and maintain employment. Additionally, the process of proving they are too sick to work can be complex and time-consuming, especially for those without stable housing or access to medical records.
Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, said the federal regulations are stricter than many states had expected. “It took everyone by surprise,” Tolbert said. Mehmet Oz, who leads the Centers for Medicare & Medicaid Services (CMS), touted the regulations as a “path to prosperity” during a press conference in June. However, 25 mostly Democratic-led states sued the Trump administration over the regulations, arguing the medical frailty standard would be too hard for enrollees to meet.
The Impact on Homeless Individuals
For Pugh, the new work requirements have added another layer of stress to his already challenging situation. He has tried to get into an addiction treatment program, but the waitlist is long. He has also struggled to get to doctor appointments and has lost important documents, making it difficult to prove he qualifies for an exemption.
“I’m taking it one day at a time,” Pugh said. “My Medicaid is still active, but when are they gonna cut that off from me? I can’t get employed. How am I supposed to survive?”
The Role of State Exemptions
Some states have attempted to include homelessness as an exemption, but federal officials have said that’s not allowed. In Montana, lawmakers also planned to excuse people fleeing domestic violence and caregivers of hospitalized family members, but these groups are also left off the federal exemption list.
Federal officials have said many people who are homeless could fall under another exemption, such as being too sick to work. However, like many states, Montana’s system to automatically conduct those checks through existing medical records isn’t ready. Health department spokesperson Jon Ebelt said it should be in place by October. Anyone not automatically exempted by the state would have 30 days to prove their case.
As the deadline for implementing the new Medicaid work requirements approaches, homeless individuals like Pugh continue to face significant challenges. Without stable housing, access to medical care, and the support they need to meet the new criteria, many fear they will lose their healthcare coverage and fall further into poverty.
