- EXCLUSIVE: Experts are raising alarms over the feasibility of Trump’s ‘One Big, Beautiful Bill,’ particularly its Medicaid work requirements, which would force nearly 20 million Americans to verify their hours worked, studied, or volunteered. Former Treasury and state health officials told Fortune the already understaffed agencies lack the infrastructure to manage the surge, warning of possible system breakdowns, long wait times, and millions losing coverage by 2034.
While economists argue over whether President Trump’s “One Big, Beautiful Bill” (OBBB) will add to national debt or manage to offset the “largest tax break in history” with tariffs, some experts are worried about the practicality of the plan.
More specifically, those who have worked on the ground to enact political promises in the past are questioning how the White House’s proposals will trickle into reality.
President Trump’s bill checks many boxes for his voters and for Republicans: new work requirements for Medicaid recipients, no taxes on tips, a higher maximum child tax credit threshold, and a raise of the limit for state and local tax deductions (SALT).
But one former Treasury staffer told Fortune that increasing the procedural legwork for an operation as big as Medicaid by the deadline of January 2027 may be a customer-service nightmare waiting to happen.
Julie Siegel is the former Deputy Federal COO at the Office of Management and Budget (OMB), and served as Deputy Chief of Staff at the Department of Treasury under Janet Yellen.
With the OMB, Siegel oversaw the U.S. Digital Service tasked with developing the technology to enact federal departments’ needs. She already has concerns about the tweaks to Medicaid, given her experience.
She told Fortune: “Medicaid is a federal and state partnership, they have to administer it and essentially build a machine to administer this new set of bureaucracy that the tax bill is putting on them.”
“And they can’t do it. There are 30% vacancies in some of these agencies, they’ve been stretched through COVID, they’re stretched because grants and other sources of revenue are being cut through DOGE [the Department of Government Efficiency] and they basically have 18 months to do this huge thing.”
A spokesperson for the U.S. Department of Health and Human Services (HHS) told Fortune the Centers for Medicare and Medicaid Services (CMS) is implementing the changes in order to strengthen the long-term viability of Medicaid.
“The new law honors that mission by better aligning incentives to protect those the program was designed to serve while helping able-bodied, working-age adults engage more fully in their communities,” HHS added. “States have primary responsibility for verifying eligibility for their Medicaid programs, and CMS is actively engaged in providing technical assistance to ensure eligibility, verification, and enrollment systems are secure, efficient, and tailored to each state’s operational capacity.”
18.5 million people will have to prove they meet the requirement every year
The task is to verify that individuals meet the new requirements: Namely that they have done 80 hours a week of month, or community engagement, or education—similar to policy already in place in some states.
The question for consumers is how to gather the evidence to prove they meet these benchmarks. In many cases employees, students or volunteers will not have a timesheet proving the hours they clocked in and out in a given week. The question for government administrators is how to verify and process that information.
The problem is no small one. According to the Congressional Budget Office’s predictions some 18.5 million people will have to prove they meet the requirement every year once the legislation is implemented in all states. And those individuals will also have to prove their status once every six months. That will create an avalanche of data for authorities to sort and verify on a rolling basis. At present, they have little information about where to begin.
Robert Gordon has overseen data administration work on a huge scale in the past, having served as director of the Department of Health and Human Services for the State of Michigan during the COVID pandemic, as well as assistant secretary for financial resources at the U.S. Department of Health.
Gordon said at the moment there are a “tonne of unanswered questions” about the legislation, so much so that some states may even begin building systems to process the changes without the answers from central government.
The solution is not straightforward but it is clear, Gordon tells Fortune: “[Government officials] need to enable and encourage states to access the flexibilities that are in the law. Doctor Oz has talked about how they’re going to provide technology that enables simple and easy verifications for both individuals and states. He should be good to his word, simple as that.”
HHS told Fortune that while states will bear the responsibility for verifying eligibility, it is working closely with these departments on ways to improve their systems. This could include helping state departments build or enhance data-sharing agreements, integrate real-time verification tools into platforms, and streamline document processes for individuals.
CMS is also parachuting in experts from the federal government to provide insight on such projects, with the spokesperson adding: “CMS is already working with state Medicaid directors to prepare for these requirements and is running two demonstration projects with promising results. We are confident the technology and infrastructure already exist to support successful implementation.”
What does this mean for consumers?
From her experience, Siegel has her suspicions about what happens next: “[Government] will try and build websites to do this, and I think there’s a good chance those web builds don’t work. When the websites break down, people call, when call centers are understaffed which they are likely to be, wait times are super long.”
“And when you can’t get through, you’re eight months pregnant and you want be covered by Medicaid, you call, your partner calls, your parents call, your grandparents, all start to call. That’s how these call centers go. People can’t get through, and so they show up at the local office and there’s a line around the block. Unfortunately I’ve been through these situations—not in a Medicaid context—and the customer service has been really poor while we’ve been trying to work through it. The staff have mandatory overtime which gets cancelled, they’re yelled at for a bunch of hours a day, and the attrition goes up.”
So begins a “vicious spiral” of overstretched staff trying to sift through millions of queries—some from individuals who simply no longer qualify for cover.
HHS said it “recognize[s] the importance of minimizing disruptions for eligible families and ensuring no one is improperly disenrolled due to delays in verification or administrative barriers.”
It added: “CMS remains committed to providing ongoing policy, systems, and operational tools and guidance to state agencies to support timely implementation in a manner that protects eligible individuals and families. CMS will continue working with states, community partners, and other federal agencies to ensure reforms are implemented fairly, lawfully, and with the infrastructure in place to support a smooth transition for beneficiaries.”
According to a research letter published in the Journal of the American Medical Association (JAMA) some 7.6 million people will become uninsured by 2034 because of the changes to the Medicaid policy.
Gordon’s fear is that families and individuals simply don’t have the time or capacity to organize their coverage under the new scheme, saying: “People are very busy, they have a lot of strain in their lives, they have a lot of things to worry about that arise organically in their jobs and their families in their everyday lives and I think a good philosophy of government is not to add add to those burdens and those challenges, but that’s not the philosophy of this bill.
“And so, I I think there’s going to be a lot of of inevitable breakage, and it will be the job of government to minimize that breakage.”
Of course, the headache consumers may be barreling toward is not of the Trump administration’s volition alone. Some may argue that previous admissions could have invested and developed systems to improve the Medicaid service, meaning the OBBB would not pile more strain on an already stretched system.
“There’s a moment here for ‘State,'” Gordon, a visiting fellow at Georgetown University, added. “There is a moment for governors to step up and try not only to minimize coverage loss, but also to modernize, and that’s very hard to do because the most natural thing will be to pour new wine into old vessels.”
