Medicaid Work Rules Threaten Maternal Coverage
New federal Medicaid work requirements are forcing states to spend millions on system overhauls, sparking fears of coverage loss for pregnant individuals. Meanwhile, hospitals are already making cuts in anticipation of funding strains, creating a dual risk of patients losing insurance and provider budgets shrinking.
The new rules, part of the "One Big Beautiful Bill Act" signed into law in July 2025, mandate that most non-exempt adults aged 19-64 in Medicaid expansion states work, volunteer, or attend school for at least 80 hours per month. This federal change is scheduled to take effect by January 1, 2027, though states can implement it sooner and some, like Nebraska, plan to do so as early as May 2026. While pregnant and postpartum individuals are listed as exempt, policy experts warn that administrative burdens and documentation requirements could still lead to coverage gaps. These disruptions in insurance are linked to patients missing essential prenatal and postpartum care, which can worsen health outcomes for both mother and baby. Medicaid currently covers 41% of all births in the United States. Historically, the implementation of similar work requirements has led to significant coverage losses. When Arkansas briefly implemented a work requirement in 2018, about 18,000 people lost their health insurance before a federal judge halted the program. The Congressional Budget Office estimates the new federal rules will cause over 5 million people to lose insurance by 2034. The requirements are also proving costly for states to implement. An Associated Press review found that the necessary technology upgrades and additional staffing will likely exceed $1 billion nationwide. For example, Missouri is fast-tracking $32 million for system upgrades and anticipates needing 120 new employees, while Maryland and Colorado project costs over $32 million and $51 million, respectively. These state-level costs come as hospitals brace for major revenue shifts. The 2025 reconciliation law is projected to cut federal Medicaid spending by $911 billion over ten years. This reduction in funding, combined with an expected rise in uncompensated care costs as people lose coverage, could lead to a 19% decline in operating margins for hospitals in expansion states, with safety-net hospitals facing a potential 56% reduction. This policy shift occurs against a backdrop of a worsening maternal mortality crisis in the U.S., which already has the highest rate among developed nations. Maternal deaths nearly doubled between 2019 and 2021 before decreasing in 2023, and significant racial disparities persist. States that have not expanded Medicaid already see maternal death rates that are 18% to 49% higher than states that have. Midwifery care has been identified as a key strategy for improving maternal health outcomes, but access is inconsistent. While all 50 states regulate and license Certified Nurse-Midwives (CNMs), regulations for other types of midwives vary, creating barriers to practice. Though 37 states license non-CNM midwives, only 19 provide Medicaid reimbursement for their services. The American College of Nurse-Midwives and other professional organizations have advocated for policies that expand access to midwifery care as a way to combat the maternal health crisis. The new Medicaid rules and associated state budget pressures create uncertainty for efforts to integrate more midwives into the healthcare system, a profession already facing workforce shortages despite projected growth.
