As the rules set by the Centers for Medicare and Medicaid Services finally offer the states some guidance on how they may roll out the new compulsory Medicaid work requirements, blue states are doing the kinds of things you might expect. Liberal leaders are pursuing creative ways to minimize the impending damage, or even seek to delay its implementation. Here, they’re caught between a rock and a hard place: These good-faith efforts might mitigate some of the harms, but they may prove costly to Democratic accountability following Congress’s enactment of America’s broadest assault on the safety net.
H.R. 1, or the so-called “One Big Beautiful Bill,” was an earthquake to the American safety net. It not only imposed a 20 percent funding cut to our nation’s food assistance program, it also cut nearly $1 trillion from Medicaid, a bedrock safety net program on which low-income children and adults depend for health insurance. And as part of this historic cut, Medicaid expansion enrollees must document that they are still eligible, whether because they are working at least 80 hours per week or because they satisfy an exemption category.
In perhaps the clearest reflection of Republicans’ cognizance of the law’s impact on a health insurance program that has enjoyed bipartisan support, they carefully delayed the law’s most damaging effects until after the midterm elections and anchored many of the cuts in the imposition of administrative burden, a strategy far more covert than, for example, the “repeal and replace” rhetoric of 2017.
Medicaid, a health insurance program with shared responsibility between the state and federal governments, has historically left states with significant flexibility in administration. H.R. 1 marks a striking departure from this approach by compelling states’ implementation of work requirement programs that will result in more uninsurance and strain on regional health systems. Although adopting work requirements is compulsory, states retain meaningful discretion over how they are administered. Those choices will shape health care access for millions, but they may also carry unexpected political costs.
States can reduce the damage by relying on existing government data to verify eligibility automatically, minimizing documentation requirements for caregivers and medically frail enrollees, and even seeking waivers to delay implementation until January 2029. In that case, voters would decide on the next president of the United States before experiencing the pain of H.R. 1’s reach.
Democrats face a conundrum. They have good reason to want to safeguard Medicaid enrollees’ health care access, because of both the party’s broad political commitment to health care access and economic concerns about hospital closures. If Democrats fail to intervene in this dangerous policy, the devastation will not just hit marginalized communities—though without a doubt, Medicaid enrollees will face the greatest cost as they find themselves ensnared in red tape and risk the loss of health coverage. In a country with notably expensive health care, coverage loss will assuredly lead to delayed care, potentially resulting in worse health outcomes and financial devastation. Moreover, as hospitals absorb more uncompensated care, they may cut services or close altogether, with ripple effects for emergency care, privately insured patients, and local economies.
But stopping the bleeding from this anything-but-beautiful law risks obscuring for voters the damaging effects of hollowing out the safety net.
Democrats have a history of seeking to bail Republicans out of bad policymaking, most notably amid the shutdown over the expiring marketplace subsidies. While putting people over politics can be viewed as noble and faithfully dedicated to safeguarding health care access, it fails to appreciate how this can impede Democratic accountability when voters cannot appreciate the horrors that Republicans in Congress have wrought.
Public confusion is pervasive. KFF’s June 2026 tracking poll revealed that just 51 percent of respondents understood that H.R. 1 would result in cuts to Medicaid, with the remainder expressing confusion as to whether funding would increase or stay the same. In my own May 2026 survey of 2,064 U.S. adults, 54 percent of respondents who supported increasing Medicaid funding nevertheless also supported the One Big Beautiful Bill Act.
KFF finds that support for the legislation declines from 35 percent to 21–25 percent when respondents are informed that the law will increase the uninsurance rate and strain local hospitals, suggesting that preferences are movable but demand effective communication, a task with which the Democrats have historically struggled.
This is hardly the only source of confusion within Medicaid policy. Many Medicaid enrollees are unaware that they are enrolled in Medicaid, a dynamic exacerbated by many states’ decisions to rename their programs (e.g., to “Husky” or “BadgerCare”) in an effort to destigmatize Medicaid, as well as by roughly three-quarters of Medicaid being administered by private insurers like UnitedHealthcare and Humana. This dynamic contributed to political scientist Suzanne Mettler characterizing Medicaid as part of a “submerged state,” with many Americans unable to trace the role of government to their receipt of critical social benefits.
It is little wonder, then, why many Medicaid enrollees have not been attuned to these policy transformations, with an April 2026 Health Management Academy survey of Medicaid enrollees finding that a striking 55 percent of Medicaid-enrolled respondents were unaware of the impending work requirements.
Voters already face significant informational demands. It’s not common knowledge that the One Big Beautiful Bill immediately devastated Medicaid funding, even though the effects are spread out over time. Nor is it easy to understand that “BadgerCare” and the like are actually Medicaid. Furthermore, the connections between (for example) Medicaid coverage losses and rural hospital closures are not abundantly clear to anyone who’s not hyper-attuned to these policy debates. Any blue- or purple-state efforts at damage control or delayed rollout will further obscure the recklessness with which Republicans have slashed the programs that allow people to pull themselves up, and which actually promote life.
This does not mean that the Democrats need to sit idly by as people lose coverage. But it does mean that the Democrats need to take victory laps when they engage in the unsexy but essential work of administrative burden reduction—victory laps that they have historically been loath to take.
Democrats have made this mistake before. After the Affordable Care Act and again after the Inflation Reduction Act’s drug pricing reforms, they quickly shifted to the next legislative fight instead of explaining to voters what they had accomplished. They may find repeated credit claiming to the effect of “Thanks, Obama!” or “Thanks, Biden!” impolite, but it is part of governing in a democracy. Even Trump, who cannot be said to be good at either “governing” or “democracy,” knows the value of publicly spiking the football, regardless of whether he’s actually scored.
There are lessons that Democrats should borrow from Trump, the biggest being: Branding matters. And unlike Trump’s application of lipstick to the proverbial pig, the Democrats’ policies are actually good and popular—if people understand what they are. But voters often need help connecting the dots between policy design and outcomes, especially with the nuances involved in tracing coverage losses to uncompensated care and hospital closures.
In this setting of policy complexity and an onslaught of news that can make it hard even for the observant to keep up, effective Democratic accountability demands effective communication about the One Big Beautiful Bill’s vast expanse, as well as all of the steps taken to spare enrollees from Republicans’ worst impulses.
Democratic governors taking care to minimize coverage losses must find creative and meaningful ways to explain plainly what they are doing and why. The right message might be something along these lines: “Republicans are forcing you to document your work hours to remain insured. We’re using the information we already have so you don’t have to fill out another form. The law protects caregivers and the medically frail. We’re interpreting these protections as broadly as we can and ensuring that everyone who qualifies for those exemptions actually gets them. Republicans imposed the paperwork. We’re reducing the hassle.”
American policy suffers from a damaging and unsustainable asymmetry: Democrats’ effective governance often is precluded by their ineffective politicking. But administrative burden reduction is not enough; It must be paired with explicit credit claiming. Democracy depends not only on governments solving problems, but on citizens knowing who created the problems in the first place. Every Republican burden that a Democratic governor relieves should come with a reminder of who burdened the public in the first place.
