By Tami Luhby, CNN

(CNN) — Without Medicaid, Joanna Parker would have a much tougher time holding down a job.

The Garner, North Carolina, resident works for a local home goods store up to 20 hours a week, typically. But she also suffers from degenerative disc disease in her spine and relies on Medicaid to cover her doctor’s visits, physical therapy and medication that helps her manage the pain so she can get out of bed in the morning.

“If I lose my insurance, I lose my ability to work,” said Parker, 40, who was uninsured for about a decade until North Carolina expanded Medicaid to low-income adults in December 2023.

That’s why Parker is so worried about the sweeping Republican tax and spending cuts package that the Senate narrowly approved on Tuesday. The bill, which passed the House by a slim margin in May, would impose the first-ever work requirement on Medicaid enrollees like her. Lawmakers hope to send the legislation, which aims to fulfill President Donald Trump’s agenda, to his desk before July 4th.

Though she’s employed, Parker fears she could be stripped of her health insurance if she’s not able to work enough hours every month or gets tripped up in reporting her time on the job to the state – should the work mandate become law. She is now facing the potential need for a biopsy so she’s even more worried that she could be left without insurance.

“I feel it will be so easy to lose your coverage if you do the reporting the wrong way and you can’t fix it,” said Parker, who has applied for full-time jobs over the past 18 months but said she hasn’t received responses.

The Senate GOP’s “big, beautiful bill” would mandate that many Medicaid expansion enrollees ages 19 to 64 work, volunteer, go to school or participate in a job training program at least 80 hours a month to obtain or maintain coverage. The requirement, which would go into effect by the end of 2026, would not apply to parents with children under age 14, pregnant women, medically frail individuals and those with substance-abuse disorders, among others. (The House version would exempt all parents with dependent children.)

The provision would help achieve Republicans’ longstanding goal of introducing work requirements into Medicaid. It’s part of an unprecedented set of cuts that GOP lawmakers would make to the nation’s safety net program.

Proponents say the mandate would prompt enrollees who could – and should, in supporters’ view – work to get jobs and, eventually, move off of Medicaid. Also, they argue, it would preserve the program for the most vulnerable Americans and reduce spending on the low-income adults who gained coverage through the Affordable Care Act’s expansion provision, a frequent target of congressional Republicans.

“If you are an able-bodied adult and there’s no expectation of you to work or train or volunteer in any way, there’s going to be a large number who don’t,” said Jonathan Ingram, vice president of policy and research at the Foundation for Government Accountability, which promotes work requirements in government assistance programs.

But many Medicaid enrollees and their advocates fear millions of people would lose their coverage under the proposed measure, including many who already work or qualify for an exemption but would get stuck in red tape.

An estimated 5.2 million Medicaid recipients would lose their coverage over 10 years because of the work mandate, and few would have access to job-based insurance, according to a Congressional Budget Office analysis of the House bill. Overall, the legislation would leave nearly 11 million more people uninsured in 2034, according to CBO.

CBO has not released a detailed breakdown of the impact of the bill passed by the Senate, but a preliminary estimate from Sunday found that it would result in nearly 12 million more people being uninsured in 2034. (The final version of the bill included a change that would likely reduce the number of uninsured by more than 1 million people.)

On Medicaid and working

Many adults with Medicaid coverage have jobs, though the estimates vary.

Some 38% of adult enrollees had full-time jobs in 2023, most of them for the full year, according to KFF, a nonpartisan health policy research group that looked at folks ages 19 to 64 without dependent children who did not receive disability benefits or have Medicare coverage, which insures people with disabilities. Just over 20% worked part time, up to 35 hours a week.

Another 31% reported that they did not work because they were caregivers or in school or had an illness or disability, all of which might qualify them for exemptions from the work requirements under the House bill.

Only 12% of the enrollees said they were not working because they couldn’t find jobs, had retired or reported another reason, according to the KFF analysis, which is based on US Census Bureau data.

“Most people are doing the things that they’re expected to do in terms of qualifying activities or things that could qualify them for an exemption,” said Michael Karpman, principal research associate at the Urban Institute. “But people have a lot of difficulty navigating the process for reporting their exemptions, or if they’re not exempt, reporting their work activities.”

He pointed to Arkansas, the first state to temporarily implement work requirements during Trump’s first term before the effort was halted in federal court. More than 18,000 Medicaid enrollees lost their coverage over several months – even though the state automatically exempted about two-thirds of those subject to the mandate.

Many beneficiaries in Arkansas did not understand the work requirements or did not realize it applied to them, a 2019 Urban Institute report found. Participants tend to move frequently so their contact information may have been outdated. Others had difficulty using the online reporting portal, especially if they did not have access to computers and internet service.

“That population has all kinds of challenges with interacting with a system like that,” said Bill Kopsky, executive director of the Arkansas Public Policy Panel, a social and economic justice advocacy group. He noted that many enrollees didn’t receive mailed notifications from the state or didn’t realize they had to take action.

What’s more, the mandate was not associated with an increase in employment, though the uninsured rate did rise among low-income residents in the affected age group, said Karpman, who analyzed Census data in a recent report. That finding is in line with a previous study from Harvard University researchers, which was based on telephone surveys.

Ingram, however, challenges the assertion that the effort did not spur Medicaid recipients to find work. He noted in a recent report that more than 9,000 enrollees found jobs during the time the work requirement was implemented. Some 99% of them were in the age group subject to the mandate, according to a prior foundation report that cited state data.

Can’t afford to lose Medicaid again

Katrina Falkner knows what it’s like to be stuck in a Medicaid paperwork morass. The Chicago resident, who cares for her elderly father and other family members with disabilities, said she was disenrolled from the program in 2023 after the state Department of Human Services lost the paperwork that she had spent days organizing.

The agency told her that it reinstated her, she said. But when she went to the hospital, she found out she was still uninsured. It took several visits to multiple agency offices before the issue was resolved the following year.

The department told CNN that such scenarios are “extremely rare” and it works to “ensure timely review and enrollment” for all applicants eligible for Medicaid.

Falkner, 43, volunteers with several community organizing groups at least 20 hours a week and works every other Saturday as a Head Start ambassador for the Chicago Early Learning program. She also suffers from asthma, anemia, vertigo and other conditions, which can make it hard for her to work or volunteer at times. Being able to meet the reporting requirements concerns her, especially since her electricity and internet access are sometimes cut off.

“If I lost my Medicaid, it would cause me a whole lot of struggles,” she said, noting that the program covers her nebulizer and other health care needs. “If they don’t have the right documents, I won’t be able to be in existence because I can’t breathe.”

Although Dana Bango of Zionville, North Carolina, has dealt with state social service agencies for years, she still “sweats it every time.” There are many strict deadlines and hoops to jump through, so she has to remain vigilant, she said.

The potential work mandate fills her with “dread” since she’s worried that she could fall through the cracks and lose her Medicaid coverage – even though she works 20 hours a week at the North Carolina Christmas Tree Association and delivers for Door Dash 10 hours a week.

A cancer survivor who still needs follow up care, Bango, 57, is concerned that she may not get the help she could need from state workers to log her hours if the mandate takes effect.

“I’ve been uninsured before. I don’t want to go back there. It’s a scary thing,” she said. “This adds more stress, which will lead to more health issues. It’s not good for low-income working people like us.”

This story has been updated with additional developments.

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