Up to 19,000 Granite Staters Could Lose Medicaid Coverage Under Potential Federal Work Requirements

May 5, 2025 | Jessica Williams
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Amid ongoing budget reconciliation negotiations among federal policymakers, the U.S. Congress could likely introduce a Medicaid work requirement, among other significant proposed changes to the Medicaid program. While specific work requirement legislation is not yet known, a proposed federal mandate could be similar to that outlined in the Limit, Save, Grow Act of 2023.

Using a methodology that draws on New Hampshire’s previous work requirement proposal as well as the impacts of Medicaid work requirements in Arkansas, recently-released data from the Urban Institute estimates that up to 19,000 Granite Staters could face coverage termination under potential federal Medicaid work requirements.

Potential Implementation of Federal Medicaid Work Requirements

The Limit Save Grow Act —passed by the U.S. House in 2023 but not advanced by the Senate or enacted into law— would have required states to enforce Medicaid work requirements or risk losing federal Medicaid match funding. The bill mandated that Medicaid recipients aged 19 to 55 engage in work, a work program fitting a certain federal definition, or another community service activity for a minimum of 80 hours each month. In addition, states would have risked losing federal dollars for an enrollee if that enrollee failed to comply with the work requirement for “three or more proceeding months” during a calendar year.

While most working-age adults would have been required to comply, the prior bill did include exemptions for certain Medicaid enrollees. These exemptions included, but were not limited to:

  • Parents and caretakers of dependent children or those with a disability,
  • Pregnant women,
  • Individuals in substance use treatment,
  • Students attending school at least half time,
  • People already complying with federal work requirements, such as those required by the Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF), and
  • Adults “physically or medically unfit for employment” as indicated by a physician or other medical professional, while not specifically exempting those eligible for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) from the work requirements.

The Congressional Budget Office (CBO) estimated in 2023 that the Limit, Save, Grow Act would have required about 15 million enrollees to comply with the Medicaid work requirements, with around 1.5 million adults projected to be noncompliant and at-risk of losing coverage due to the loss of federal matching funds. While it is still unclear if, and to what extent, the Limit, Save, Grow Act could be reintroduced during the current federal budget reconciliation process, publicly available information indicates that future proposed language could resemble that included in the prior bill.

New Hampshire Tried This Before and Almost 17,000 People Lost Coverage

Upon obtaining federal Section 1115 Medicaid waiver approval in 2018, the State of New Hampshire began the process of implementing Medicaid work requirements in 2019 for all adults enrolled in the State’s Granite Advantage Health Care Program. As a result of the federal Patient Protection and Affordable Care Act (ACA) and the subsequent 2014 Medicaid Expansion in New Hampshire, the Granite Advantage Program expanded Medicaid health coverage to adults ages 19 to 64 with annual incomes up to 138 percent of the federal poverty level, or $21,597 for an individual and $36,777 for a family of three in 2025.

Under the State’s implementation as prescribed in RSA 126-AA:2, III, Granite Advantage adults were required to work, participate in a related job readiness or related educational program, or participate in another community service activity for a minimum of 25 hours a week, totaling 100 hours each month, higher than the 80 hours per month required under the federal Limit Save Grow Act. Exemptions were permitted, but not limited to:

  • Adults in mental health or substance use treatment,
  • Parents or caretakers of children up to 12 years old, with only one parent exempt in the two-parent household,
  • Pregnant women,
  • Beneficiaries in compliance with other federal work requirements under SNAP or TANF, and
  • Adults experiencing a disability or caring for someone with a disability.

New Hampshire distinguished itself from other states by seeking work requirements applicable to adults aged 55 to 64, with older adults typically having lower workforce participation rates compared to younger age groups.

In July 2019, the State temporarily suspended the Granite Advantage work requirement after concluding that close to 17,000 adults would lose coverage. Based on New Hampshire Department of Health and Human Services (DHHS) data from June 2019, around half of the Granite Advantage population (24,766 adults) did not have an exemption and were required to meet work requirements. Of that number, around a third (8,129 adults) reported meeting requirements as of July, while about two-thirds failed to comply (16,637 adults).

Shortly after the State’s suspension of the requirement, a federal judge permanently halted New Hampshire’s Medicaid work requirements, stating concern around potential coverage losses. Due to this ruling, future implementation of these work requirements in New Hampshire would depend on either a successful appeal of the current ruling or the submission and federal approval of a different State Medicaid waiver request.

Introduced during the 2025 legislative session, Senate Bill 134 would require the DHHS to resubmit a Section 1115 waiver to the federal government seeking to implement the work requirements defined in existing State statute that New Hampshire began implementing in 2019. While Senate Bill 134 has been tabled by a New Hampshire House Committee after it passed the Senate, State lawmakers could still opt to include language around Medicaid work requirements in their State Budget proposal for the upcoming biennium. Members of the House Finance Committee introduced an amendment that would have required a Medicaid waiver submission for reinstating the work requirement, although the amendment was withdrawn due to pending action on the Senate bill.

Nearly One in Three Granite Advantage Adults Could Lose Coverage

According to the Urban Institute’s analysis of Medicaid work requirements, Urban Institute estimates suggest that approximately 17,000 to 19,000 Granite Staters could lose coverage if a federal work requirement were to be implemented. As of March 31, 2025, 59,667 adults ages 19 to 64 were enrolled in the State’s Granite Advantage Program, which is likely to be the category of enrollees most directly impacted by work requirements in the model of the Limit, Save, and Grow Act. When applying the number supplied by the Urban Institute’s analysis to DHHS-specific caseload data, the equivalent of approximately 28 to 32 percent, or nearly a third, of Granite Advantage adults could lose coverage under these estimates; this does not account for Granite Advantage adults ages 55 to 64 who may not be subject to work requirements if the federal government reintroduces language similar to the Limit, Save, Grow Act.

According to national 2023 data from the Kaiser Family Foundation, approximately 64 percent of Medicaid adults are already working at least part-time, with around 44 percent engaged in the workforce full-time; this data includes adults ages 19 to 54 who are not covered by SSDI, SSI, or Medicare. Approximately 29 percent of enrollees faced barriers to employment, including caregiving responsibilities (12 percent), illness or disability (10 percent), and school attendance (7 percent). The remaining 8 percent identified that they were retired, unable to find work, or another reason not specifically indicated. According to separate KFF data, approximately 65 percent of New Hampshire’s Medicaid-enrolled adults are working, aligning with these national trends.

Despite high estimates of employment among beneficiaries, those who are working may not have predictable schedules. This includes seasonal employees or involuntary part-time workers who may face challenges in meeting consistent monthly work requirements. Many part-time or seasonal jobs that Medicaid adults hold do not provide health insurance benefits, making public health coverage the only option for those with the lowest incomes or in between seasonal employment opportunities.

In addition to the potential for unstable employment, administrative hurdles could also terminate coverage for many adults, even if they are actively engaged in the workforce. Implementation of a work requirement could increase required paperwork for beneficiaries, with proof of employment likely required on a regular basis to meet reporting requirements. Work requirements could also create administrative burdens for the state, particularly during the initial implementation stages. The Government Accountability Office (GAO) estimates that New Hampshire spent up to $6.1 million during the initial implementation of work requirements, including money spent on extensive outreach efforts to inform Medicaid enrollees of the pending requirements.

Experiences from Other States

New Hampshire is among approximately 15 states that have submitted or have taken legislative steps this year toward submitting a Section 1115 Medicaid waiver to implement work requirements for enrollees; only two states, Arkansas and Georgia, have ever implemented such requirements.

During Arkansas’ implementation in 2018, approximately 18,000 adults lost coverage within seven months before a federal judge halted the state’s work requirements due to coverage losses. Independent research later found Arkansas’ work requirement to be associated with an increase in uninsured rates, with no associated increase in employment.

Georgia is the only state with an active waiver for work requirements among its newly created Pathways to Coverage Program, despite not having previously implemented Medicaid Expansion for adults with low incomes. According to research around implementation, the state spent an estimated $32 million on administrative costs before the program even began, with lower enrollment during the first year than was originally projected.

What’s Next for New Hampshire

As the U.S. Congress continues budget deliberations in May, federal lawmakers will likely provide more clarity relative to the possible introduction of work requirements for Medicaid enrollees. New Hampshire’s experiences in 2019, combined with new estimates from the Urban Institute, provide valuable insight into the challenges Granite Staters may encounter if Medicaid work requirements are imposed, including the potential for thousands to lose health coverage despite already working.