The Medicaid Work Requirements Start in 2028. For People in Active Treatment, the Clock Is Already Running.

The administration and its allies have been consistent about one talking point regarding the One Big Beautiful Bill’s Medicaid provisions: SUD treatment is protected. Cost-sharing for substance use disorder services is explicitly exempted. Mental health treatment is exempted. The people who need care the most won’t be pushed out of care. This is the claim.

Here is what is actually true. SUD treatment services are technically exempted from cost-sharing requirements that take effect October 1, 2028. That’s accurate. What is not exempted — what is in fact the mechanism that will do the most damage — is the work requirement itself. Medicaid expansion adults, the coverage category that is the primary insurance pathway for the 48.5 million Americans with a substance use disorder, will be required to document 80 hours per month of work, job training, education, or community service, or demonstrate a qualifying exemption, to maintain enrollment.

People in active SUD treatment are, by definition, people managing a condition that impairs cognition, decision-making, and administrative function. The requirement is not “get better and then prove you’re working.” The requirement is continuous, administrative, and begins regardless of treatment status. The research on Medicaid work requirements — conducted during previous implementation periods in states like Arkansas, where the program was enjoined — shows that the primary driver of coverage loss is paperwork failure, not actual ineligibility. People who qualified lost coverage because they couldn’t navigate the documentation system in time.

States that expanded Medicaid under the ACA saw a 55 percent higher rate of SUD treatment utilization than non-expansion states, according to KFF analysis. That improvement is at direct risk. If expansion adults — disproportionately people with SUD, serious mental illness, and co-occurring conditions — lose coverage at the rates prior work requirement implementations suggest, the treatment gains of the past decade reverse. Not slowly. Abruptly, in October 2028.

The exemptions for SUD treatment services don’t help a person who loses Medicaid enrollment before they can access those services. They don’t help someone in residential treatment who has no capacity to file monthly work-activity reports from a treatment bed. The provision, as designed, creates a technical protection for a service that many people will be unable to reach because they’ve already fallen off the enrollment rolls.

This is the correct level of specificity at which to think about “Medicaid cuts.” Not the headline $1 trillion over ten years — though that’s real — but the mechanism: a documentation requirement imposed on a population whose defining condition impairs documentation, connected to a benefit that is the only insurance pathway to treatment.

The 2028 clock is running. Providers who serve Medicaid patients need to start building navigation capacity now: helping patients understand what will be required, identifying who qualifies for exemptions (disability status, caregiving, medically frail designation), and flagging the administrative support needs for the most vulnerable people in their caseloads. Two years feels long. The system-level response to this will need to start well before enrollment verification kicks in.

Coverage at /newsroom/category/policy-funding.