---
type: source
title: "OBBBA Medicaid Work Requirements: December 2026 Deadline, 7 States Pending Waivers, CMS Rule Due June 2026"
author: "AMA / Georgetown CCF / Urban Institute / Modern Medicaid Alliance / King & Spalding"
url: https://www.ama-assn.org/health-care-advocacy/federal-advocacy/changes-medicaid-aca-and-other-key-provisions-one-big
date: 2026-01-23
domain: health
secondary_domains: []
format: report
status: processed
processed_by: vida
processed_date: 2026-04-08
priority: high
tags: [OBBBA, Medicaid, work-requirements, coverage-loss, access, implementation, VBC, policy]
extraction_model: "anthropic/claude-sonnet-4.5"
---

## Content

OBBBA Medicaid work requirements implementation timeline and current status:

**Federal requirements:**
- All states must implement work requirements by December 31, 2026
- CMS required to issue interim final rule by June 1, 2026 (guidance for state implementation)
- Work threshold: 80+ hours/month of work or qualifying community engagement activities for ages 19-64
- Exempt populations: parents of dependent children under 13, medically frail individuals

**Current state status (as of January 23, 2026):**
- 7 states with pending Section 1115 waivers: Arizona, Arkansas, Iowa, Montana, Ohio, South Carolina, Utah
- All 7 waivers pending at CMS as of January 2026
- Nebraska: pursuing state plan amendment rather than waiver (may implement earlier)
- Ballotpedia tracking: mandatory federal requirements coming to all states by end of 2026

**Lessons from prior implementation (Arkansas, Georgia):**
- Significant access barriers from operational challenges: system glitches, unclear reporting processes, staff/training shortfalls
- Georgia PATHWAYS experience: documentation burden resulted in eligible members losing coverage who actually met work requirements
- Arkansas implementation (pre-2019 federal court injunction): 18,000 individuals lost coverage, most of whom were actually working but couldn't navigate reporting

**Scale of projected impact:**
- Urban Institute: Medicaid expansion enrollment could fall significantly under work requirements + 6-month redeterminations
- CBO (from prior sessions): 10M uninsured by 2034 from combined OBBBA provisions
- Health and Reentry Project: specific concerns about reentry populations losing Medicaid continuity

**ACA marketplace interaction:**
- APTC (Advance Premium Tax Credits) expired 2026 — not extended in OBBBA
- Creates "double coverage compression": Medicaid cuts affect <138% FPL; APTC expiry affects 138-400% FPL
- Both coverage sources simultaneously contracting for different income bands

## Agent Notes

**Why this matters:** The December 2026 deadline means ALL states must implement by end of year — this is not a pilot or a waiver program anymore. It's a national structural change to Medicaid eligibility. The VBC implications I noted in Sessions 8 and 13 are fully applicable: VBC requires 12-36 month enrollment stability for prevention paybacks, and work requirement churning destroys that stability.

**What surprised me:** Nebraska pursuing a state plan amendment (SPA) rather than a waiver — this may allow faster implementation without CMS approval. SPAs face a different regulatory pathway. If Nebraska succeeds, other states may follow the SPA route to implement before June 2026 CMS rule.

**What I expected but didn't find:** Data on which states are most likely to implement before December 2026 (voluntary early adopters vs. mandatory deadline states). The 7 pending waivers suggest these states are trying to move faster. A table of state implementation timelines would be valuable for the next session.

**KB connections:** Directly extends: (1) VBC transitions stall at payment boundary — work requirement churning destroys the enrollment stability VBC requires; (2) OBBBA Medicaid cuts from Sessions 8/13; (3) double coverage compression mechanism. Connects to the GLP-1 metabolic rebound finding — Medicaid-covered GLP-1 users who lose coverage face coverage gaps that produce metabolic rebound, reversing therapeutic benefit.

**Extraction hints:** New claim: "OBBBA requires all 50 states to implement Medicaid work requirements by December 31, 2026, destroying the enrollment continuity that value-based care requires for prevention paybacks (typically 12-36 month horizons)." This directly challenges Belief 3's VBC-as-structural-fix claim — if enrollment continuity is structurally disrupted, VBC cannot demonstrate prevention ROI.

**Context:** AMA, Georgetown CCF, Urban Institute, Modern Medicaid Alliance, King & Spalding are independent sources with different perspectives (medical advocacy, academic, consulting) — convergence across these sources is credible. Ballotpedia is descriptive/neutral.

## Curator Notes (structured handoff for extractor)

PRIMARY CONNECTION: VBC transitions stall at payment boundary; OBBBA Medicaid cuts (Sessions 8/13)
WHY ARCHIVED: National mandatory implementation by December 2026 is a structural health system change. The December deadline and the coverage-churning mechanism are the key facts not previously archived with this specificity.
EXTRACTION HINT: The enrollment-stability-for-VBC claim is the most novel angle here. The extractor should frame this as: OBBBA work requirements don't just reduce coverage — they destroy the enrollment stability architecture that VBC requires, making prevention investment structurally unprofitable under work-requirement churn.
