MISSOULA, Mont. 鈥 As congressional Republicans finalized Medicaid work requirements in President Donald Trump鈥檚 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鈥檛 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 鈥渉asn鈥檛 been disappointed.鈥
鈥淚鈥檓 a good worker,鈥 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鈥檛 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鈥檚 struggling to cover routine expenses, such as keeping his car running and paying his phone bill. He said he can鈥檛 afford the care he needs even on the cheapest insurance plan available to him through the Affordable Care Act鈥檚 marketplace or through his job鈥檚 health insurance plan. Even paying $60 a month for his sleep medications 鈥 one of six prescriptions he takes daily 鈥 is too expensive.
鈥淚 only saw one option,鈥 James said. 鈥淔udge the numbers.鈥
James hasn鈥檛 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鈥檛 someone sitting on his , 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 in the United States. Those who study safety-net systems say it鈥檚 extremely rare for enrollees to commit fraud to tap into that coverage. In fact, research shows in Medicaid, likely because the system is so confusing. And nearly two-thirds of people on Medicaid in 2023 had jobs, , a health information nonprofit that includes 杨贵妃传媒視頻 Health News.
Those transitioning off Medicaid may qualify for other subsidized or low-priced health plans through the Affordable Care Act鈥檚 marketplace. But, as in James鈥 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鈥檛 鈥渦se 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.
鈥淚 don鈥檛 want to be a fraud. I don鈥檛 want to die,鈥 James said. 鈥淭hose shouldn鈥檛 be the only two options.鈥
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.
鈥淚t’s going to hurt people, whether they’re playing by the rules or not,鈥 said , a health economist at Harvard University. 鈥淲e see this vilification of mostly very hard-working people who are really struggling and are benefiting from a program that helps them stay alive.鈥
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鈥檛 afford, James said, he dropped just enough hours at work to requalify for Medicaid and then soon picked up hours again. If he didn鈥檛 earn more, he said, he had no chance of saving enough money to find housing after graduating from the treatment program.
鈥淭hey鈥檒l give you a bone if you stay in the mud,鈥 James said. 鈥淏ut you have to stay there.鈥
That problem 鈥 becoming just successful enough to suddenly lose Medicaid 鈥 is common. It鈥檚 called a benefit cliff, said , who researches government aid at the University of Michigan.
鈥淚t 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,鈥 Herd said.
She said a partial fix exists called continuous eligibility, which guarantees an individual鈥檚 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鈥檚 eligibility cliff, Herd said, in which they must decide between losing access to coverage or dropping hours at work.
鈥淚t is going to be a nightmare,鈥 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鈥檛 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鈥檚 come. About a year ago, his body was breaking down. He couldn鈥檛 hold a spoon to eat breakfast without whiskey 鈥 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鈥檚 staying with a relative to save money as he and his girlfriend try to find an affordable place to rent 鈥 though even with Medicaid, finding housing feels like a stretch to him. He鈥檚 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.
鈥淓very 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,鈥 he said. 鈥淚’m constantly in fear that it’s gonna go away.鈥
As of mid-July, officials hadn鈥檛 noticed the extra $50 he makes each week.
