A Policy That Ignores Invisible Labor
Starting in January 2027, sweeping changes to the Medicaid system will require non-disabled adult beneficiaries to work or volunteer at least 20 hours per week to maintain their coverage. On the surface, the policy sounds straightforward -- a measure designed to encourage workforce participation and reduce public spending. But a closer look reveals a critical blind spot: the millions of Americans who already work grueling, unpaid hours caring for aging parents, disabled family members, and young children.
Nearly 8 million unpaid caregivers currently depend on Medicaid for their own health insurance. These are the people who bathe, feed, administer medication, manage appointments, and provide round-the-clock supervision for loved ones who cannot care for themselves. Over 40 million Americans provide this kind of unpaid care annually, contributing labor valued at approximately $600 billion -- a staggering figure that dwarfs the budgets of most federal agencies. Yet under the new work requirements, this labor counts for nothing.
The Sandwich Generation Faces Impossible Math
The consequences will land hardest on those caught in what researchers call the "sandwich generation" -- adults simultaneously caring for aging parents while raising their own children. For these individuals, the new mandate presents a cruel arithmetic: find 20 hours of paid employment per week on top of what may already be 40, 60, or even 80 hours of caregiving, or lose the health coverage that allows them to keep going.
The Congressional Budget Office projects that the work requirements will leave nearly 5 million additional adults uninsured by 2034. An estimated 18 million adults will need to comply with the new rules, and health policy experts warn that many who technically qualify for exemptions will lose coverage anyway because of the administrative burden of proving their status. Paperwork, documentation deadlines, and reporting requirements have historically caused eligible beneficiaries to fall through the cracks, a pattern well documented during Arkansas's 2018 attempt at similar mandates, which stripped coverage from more than 18,000 people in just a few months before courts struck it down.
When Caregivers Lose Coverage, the Whole System Pays
The downstream effects extend far beyond individual hardship. When family caregivers lose their health insurance, they are more likely to delay their own medical treatment, develop chronic conditions, and eventually require expensive emergency or institutional care themselves. Meanwhile, the loved ones they care for may be forced into nursing homes or long-term care facilities -- settings that cost Medicaid far more than home-based care. The policy intended to save money could end up costing the system significantly more.
Advocates are urging states to implement clear exemptions for family caregivers, create simplified documentation processes, and formally recognize caregiving as a form of community engagement that satisfies the work requirement. Some states have the flexibility to carve out these protections, but there is no federal guarantee that they will do so, and early indications suggest uneven implementation across the country.
Why It Matters
At its core, this debate forces a question that policymakers have long avoided: is caregiving work? For the millions of Americans who spend their days lifting, cleaning, comforting, and advocating for vulnerable family members, the answer is self-evident. The new Medicaid rules will test whether the American healthcare system is willing to acknowledge that reality -- or whether it will continue to treat the invisible labor holding the long-term care system together as something less than real employment.
