A Real Enrollee’s Struggle
Katie Crouch describes calling her state’s Medicaid agency as navigating a series of dead ends.
“The first time, it’ll ring interminably,” said the 48-year-old Delaware resident. “Next time, it’ll go to a voicemail that just hangs up on you. Sometimes you’ll get a person who says they’re not the right one. They transfer you, and it hangs up. Sometimes, it picks up and there’s just nobody on the line.”
Crouch is not merely frustrated. She spent months uncertain whether Medicaid had renewed her coverage. As of late March, her application was still pending. A decade ago, a debilitating brain aneurysm left her with lasting disabilities. She also holds Medicare — but Medicaid had been covering her monthly Medicare deductibles of $200. For three straight months, she bore that cost herself. For a household on a fixed income, that strain adds up quickly.
Her Story Is Not Unique
Crouch’s experience points to a problem far larger than one state’s call center. Across the country, Medicaid agencies struggle to keep enough workers to enroll applicants and respond to questions from existing members. Health policy researchers warn that worker shortages actively prevent enrollees from accessing benefits they legally qualify for.
What the New Law Demands
Congressional Republicans passed the One Big Beautiful Bill Act, which President Donald Trump signed into law last summer. The legislation introduces sweeping changes to Medicaid — and its administrative demands on states are steep.
More Work, More Often
Under this law, state agencies in Medicaid expansion states — nearly all states and the District of Columbia — must now do two things. First, they must verify whether millions of adult enrollees meet the program’s new work requirements. Second, they must conduct eligibility checks every six months instead of once a year. Together, these mandates effectively double the volume of verification work that eligibility staff must complete.
The law projects nearly $1 trillion in Medicaid spending reductions over eight years. However, that savings comes with a hidden administrative cost: more transactions per enrollee, handled by agencies that are already short-staffed. Work requirement implementation is set to begin January 1, 2027, though states may move forward earlier if they choose.
States Are Already Falling Short
State agencies were struggling long before the new law passed. Researchers and policy officials paint a bleak picture of Medicaid workforce capacity.
Missouri: A Case Study in Decline
Missouri’s Department of Social Services now employs roughly 1,000 fewer front-line workers than it did a decade ago. Meanwhile, the number of people enrolled in Medicaid and the Supplemental Nutrition Assistance Program (SNAP) has more than doubled over that same period. Agency Director Jessica Bax acknowledged the gap publicly during a November meeting.
“The department thought that there would be a gain in efficiency due to eligibility system upgrades,” Bax said. “Many of those did not come to fruition.”
Missouri is not an outlier. Backlogs and processing delays have become routine across multiple states. Jennifer Wagner, Director of Medicaid Eligibility and Enrollment at the Center on Budget and Policy Priorities and a former associate director at the Illinois Department of Human Services, offered a direct assessment: states are already “struggling significantly.” She added that these new mandates will bring “significant additional challenges.”
Why Hiring More Staff Is Harder Than It Sounds
KFF Health News contacted multiple state agencies to ask how they plan to implement the new work requirements. Many replied that they need more staff — but adding workers is not a simple fix.
A Difficult Job With Low Pay
Medicaid eligibility positions require months of training. The work is emotionally demanding. Pay is generally low. Tricia Brooks, a researcher at Georgetown University’s Center for Children and Families, knows the challenge well — she previously managed New Hampshire’s Medicaid and CHIP customer service program.
“They get yelled at a lot,” Brooks said plainly.
Furthermore, state agencies must train new hires for complex tasks: verifying gig economy employment, cross-referencing student records, and processing data from multiple benefit programs simultaneously. States with eligibility systems integrated across Medicaid, SNAP, and CHIP face added complexity. Making changes to these integrated platforms requires reconciling overlapping rules across multiple programs.
Tight Timelines Make It Harder
States must also absorb SNAP work requirement changes that took effect at the end of 2025 — complicating the workforce planning needed for Medicaid changes arriving in 2027. Implementing multiple major policy changes in a compressed timeframe consistently produces backlogs and errors, as states learned painfully during the 2023 Medicaid “unwinding” process.
The Role of Private Contractors
As state agencies struggle to scale up, private contractors step in to fill the gap — often at a price.
Maximus and the Transaction Model
Maximus, a major government services firm, holds contracts with numerous state Medicaid programs. During a February earnings call, company leadership explained that Maximus charges based on the number of transactions it completes per enrollee — not based on total enrollment. Consequently, revenue grows even as enrollment declines.
David Mutryn, Maximus’ Chief Financial Officer, told investors the company expects continued revenue growth precisely because of the additional transactions the new law will require. The company earned $1.76 billion in 2025 from its Medicaid-related business segment.
What Is at Stake for Enrollees
The human cost of this staffing gap is significant. Advocates and researchers warn that many enrollees may lose benefits they are legally entitled to — not because they fail to qualify, but because overburdened staff cannot process their cases accurately or on time.
Losing Medicaid coverage is not a minor inconvenience. Most Medicaid enrollees cannot afford health care without the program’s support. Many also do not qualify for Affordable Care Act subsidies. For people like Katie Crouch — navigating disabilities, fixed incomes, and a call center that rarely picks up — the consequences can be immediate and severe.
State agencies, advocates, and policy experts agree: without major investments in workforce capacity, the new Medicaid work requirements risk shifting administrative burden onto the most vulnerable enrollees, not the most able-bodied ones.
