Starting this January, new work mandates for a specific group of Medicaid recipients will go into effect nationwide under President Donald Trump's major 2025 tax and policy legislation. A number of Republican-governed states are implementing measures that are significantly stricter than what the federal government requires. These changes are expected to save the federal government $887 billion over the next decade, according to the Congressional Budget Office’s 2025 estimate, but they may also lead to 7.5 million fewer people having health insurance. At the center of the debate is the process by which individuals prove they are unable to work due to medical reasons. Federal guidelines allow states to accept a participant's self-attestation for the first 12 months, but at least six states are requiring immediate medical proof. Other states are considering similar measures. Health advocates are concerned that these strict requirements might make it harder for lower-income individuals to access coverage through the Medicaid program. "Someone may not be able to work, but they can’t see a doctor because they can’t afford it. So they’re now applying for Medicaid," said Jennifer Tolbert, director of state health policy and data at the research organization KFF. "But Medicaid is saying you need documentation from a provider." While several conservative states are implementing stricter versions of the federal law, Democratic officials in 25 states have filed lawsuits, arguing that the new regulations are unreasonably restrictive. Some claim that documentary evidence is necessary to prevent fraud, while others, like the conservative Foundation for Government Accountability, argue that work requirements should not be too easy to avoid. Jonathan Ingram, vice president of research and policy at the group, said self-attestation is "fraud-by-design," a policy created to maximize enrollment at the expense of program integrity. Self-attestation is done under penalty of perjury, meaning people who lie can face criminal charges, though such cases are rare. Six states—Arkansas, Idaho, Indiana, New Hampshire, North Carolina, and Ohio—have laws or policies that prohibit self-attestation for the work requirement exception starting next year. Missouri state Rep. Darin Chappell, working with the Foundation for Government Accountability, proposed a constitutional amendment to require "documentary evidence" of work or exemptions, banning self-attestation. The amendment passed the Missouri House but failed in the Senate. Chappell plans to reintroduce it next year. The new mandate applies to up to 20 million lower-income adults without children at home who are enrolled in Medicaid through an optional expansion in 40 states and the District of Columbia. The requirement does not apply in the 10 states that did not expand Medicaid. Beneficiaries will have to work or volunteer at least 80 hours each month or be in school at least half-time to qualify, with exceptions for situations like medical frailty. The Centers for Medicare and Medicaid Services issued a stricter rule in June, requiring that a condition must "significantly impair" someone's ability to work or attend school to qualify for an exemption. Currently, states generally decide once a year whether Medicaid recipients still qualify for benefits. The new law will require this to happen twice for most enrollees. Starting in 2028, states will be allowed to accept self-attestation just once each time a person enrolls. After that, documentation will be required at least every 12 months to confirm the condition still prevents them from working. The government expects states to rely more on third-party data, such as workers’ compensation claims or prescription information, to help make these determinations. For conditions not found in these databases, states can require a doctor's certification, a disability award letter, or other proof.