How Trump's Medicaid work requirements could affect mental health care

For many people who have a serious mental illness or are recovering from one, trying to get or keep a job may be overwhelming and exhausting.

Finding out that you need a job in order to keep accessing your mental health care can feel insurmountable.

Yet that may soon be the case for nearly half a million Washington residents.

Under a new rule in President Donald Trump’s recently passed “One Big Beautiful Bill,” Americans on Medicaid — the nation’s largest provider of mental health insurance — will be required to prove they are working, studying or volunteering a minimum of 80 hours a month in order to remain covered.

The bill states there will be exemptions to the work requirement for people who meet a variety of criteria, including those who are participating in substance use disorder programs, parents or caregivers of a dependent child or disabled individual, or “medically frail” individuals, which includes people with “disabling” mental disorders. But mental health advocates worry that given the complexity and invisibility of many mental health conditions, it could be difficult for people to prove they qualify.

About 40% of Americans covered under Medicaid receive mental health or substance use disorder treatment. In Washington, 25% of the state’s 1.9 million Medicaid enrollees received behavioral health services in 2024. According to a report last month from Apple Health, Washington’s Medicaid system, the proposed work requirements and other changes from Trump’s bill would cut Medicaid coverage for between 200,000 and 320,000 Washingtonians. The program is expected to lose nearly $6 billion in federal funding over the next nine years.

The bill, which offers major tax cuts to the wealthiest Americans, also proposes significant reductions to other social programs that serve some of the country’s poorest — including SNAP benefits, or food purchasing financial assistance.

Republicans in Congress who pushed the bill forward say the work requirements won’t hurt those who need the insurance coverage. Instead, they say imposing work requirements will weed out those who are defrauding or abusing the program.

Many specifics about how the work requirements will be enforced remain unclear, and that portion of the new bill isn’t slated to go into effect until 2027.

But the new rules will likely place a big burden on people with severe mental illness to try and prove that they qualify for exemptions, mental health advocates say.

“Getting the right paperwork submitted at the right time, navigating complex online systems, especially when someone is in psychosis or recently was, and is at an acute place in their recovery, I think it’s going to be really challenging for a lot of folks.” said Summer Starr, the interim director of Washington’s National Alliance on Mental Illness chapter. “Taking away people’s health care when they’re in one of the most vulnerable states of their lives is just going to exacerbate things for individuals and families.”

Vanessa Saavedra, a senior attorney with Northwest Health Law Advocates, said another challenge may be simply making sure everyone who’s currently on Medicaid or Apple Health understands whether the new rules apply to them or not.

The work requirements would only apply to those who received Medicaid under the Affordable Care Act’s Medicaid expansion, which allowed people to qualify for the program based on income rather than a disability diagnosis. That expansion made it easier for people with mental health conditions to receive care.

“It’s far more difficult to get the word out than you might think,” Saavedra said.

Saavedra also said if people lose mental health services as they’re dropped from Medicaid, they’ll likely rely more on crisis centers and emergency rooms — increasing the pressure on those already-overwhelmed systems.

“We know people with serious mental illness will fall through the hole this is creating in the safety net,” she said. “When people are unstable and having to rely on the ER and crisis care rather than seeking care before, that’s a major societal problem.”

Starr said as people lose mental health coverage, the pressure on caregivers — especially unpaid ones, such as family members — will also increase.

“Imagine being a family member supporting a loved one who has no access to insurance and you aren’t able to get them the care they need,” Starr said in an email. “The family members then also become responsible for navigating the system on behalf of their loved ones. This really puts more burden on unpaid caregivers. It emphasizes that as a society we do not value the caregiving field, the need for caregiving and those whose time and energy is dedicated to this on behalf of loved ones.”

Starr said more people may also end up in the jail system as a result. Since the 1970s, she said, the U.S. has removed more support services for people with mental illnesses. Many people who don’t have access to treatment instead end up in the criminal system, and increasingly, jails and prisons have become the default providers for mental health treatment.

“This is just another layer of removing support systems that will get transferred into potentially that other system,” she said.

As state lawmakers and mental health advocates await information from the federally-run Centers for Medicare and Medicaid on how the work requirements will be enforced, they’re considering the potential impact on those who need coverage, and the medical and social systems that are trying to support them.

Rep. Nicole Macri, D-Seattle, said before the Affordable Care Act — the 2010 bill that increased health care coverage for the uninsured — people who were on social programs like Supplemental Security Income, a federal program for low-income people, were eligible for Medicaid, but others were not. Currently, to qualify for SSI with a mental health-based disability, you must have very low income and assets, and the government has a detailed list of requirements for each medical condition.

Macri said the federal government could go back to using enrollment in that program as a measure for whether someone has a “disabling” mental health condition.

“If that’s the standard, then we could see people lose their coverage, and lose access to their medications and access to their mental health centers,” Macri said.

She said the federal government may ultimately come up with different standards, but said it was “hard to imagine” how people will demonstrate disability without being on SSI.

Some clinicians think Medicaid decisions could be made more specifically based on a person’s diagnosis — which could also leave people out whose conditions are not as straightforward.

Sarah Kopelovich, an associate professor at University of Washington’s Department of Psychiatry and Behavioral Sciences, said it’s not yet clear what behavioral health diagnoses will exempt someone from the work requirements.

In the mental health field, the term “disabling mental condition” typically refers to primary psychotic disorders, such as schizophrenia, and major mood disorders, like bipolar disorder. But so far, she said, there’s less clarity around things like post-traumatic stress disorder and borderline personality disorder.

Kopelovich said she’s concerned the rules won’t account for people whose conditions are not linear.

“Most of these mental health conditions that fall under this umbrella are episodic in nature,” Kopelovich said. “They will have periods of remission, but they may also have periods of worsening symptoms, and it’s very difficult if you don’t have the right work conditions where you have an employer who’s able to make accommodations to retain positions when you’re experiencing an episode.”

Macri said state agencies will be able to do some rule making, but much of the regulations will come from the federal level.

The losses in federal funding will likely be so significant that she said it’s unlikely the state can make up the difference.

“A lot of it is about where we invest our money,” she said. “It’s in what choices we make, but there’s a lot competing with that.”

She cited public education and health care as the state’s top two priorities for investment. The state has made some investments in behavioral health care, Macri said, trying to reduce the number of times people need to be hospitalized.

But she said the rule changes will likely set the system back.

“I think we’ll go back to just having a greater number of people with disabling conditions, who don’t have any health insurance,” Macri said. “And I think that’s the design — that’s how it saves money.”

Kopelovich said tying people’s right to health care to their ability to work contradicts the original goals of Medicaid.

“My concern is that this health care coverage, which is primary for this very vulnerable, high-risk population, is at stake right now in the interest of productivity,” she said. “We’re really working against our own interests if we’re not helping people to recover and then get the supports in place they need to be successful in the workplace.”

“We need to address some of the systemic challenges that our folks will face when they return to work,” Kopelovich said. “Otherwise, we’re at risk of destabilizing them, and it’s counterproductive, both from a social level and also at an individual level.”