Tywon Pugh, a 46-year-old homeless man from Montana, is struggling to access addiction treatment due to new federal regulations requiring Medicaid recipients to prove they're working or volunteering to keep their coverage. The rules exempt certain groups, including those with disabilities and Native Americans, but not homelessness as a medical condition. According to the Department of Housing and Urban Development, homelessness in the U.S. has increased by 27% from 2013 to 2025, with about 746,000 people experiencing homelessness last year. Pugh's story highlights the challenges faced by homeless Medicaid recipients who may struggle to meet the new work requirements.
Written by the local model on 2026-08-21,
using this article's own text rather than the other coverage of the
same event (that is the story summary below).
Medicaid work rule leaves homeless people in the cold
MISSOULA, Mont. —
asserted
rule → leave → cold
Tywon Pugh has seizures that make it hard to find and keep a job.
asserted
it → have → job
"They called me a 'liability to the job site,'" Pugh said, recalling the words of his manager when a seizure cost him his last job at a fast-food restaurant in this western Montana city.
asserted
seizure → call → city
When the 46-year-old lost work in the past, his wife of 10 years covered their rent and he tended to their home until he found another job.
asserted
he → lose → job
But his wife died last year.
asserted
wife → die → ?
Soon after, Pugh became homeless.
asserted
Pugh → become → ?
His problem with alcohol became worse, which made managing his seizures more difficult.
asserted
managing → become → seizures
"When she died, my whole base was depleted," Pugh said.
asserted
Pugh → die → ?
Medicaid pays for the prescriptions that keep Pugh's seizures at bay.
asserted
that → pay → bay
The government-subsidized health coverage would also pay for an addiction treatment program that Pugh says he has tried to get into, but he was told there's a waitlist.
asserted
he → subsidize → that
Pugh's goal has been to get healthy enough to work again.
asserted
goal → get → ?
But he's worried about being able to keep the Medicaid coverage he needs to get to that point.
asserted
he → keep → point
Early embrace of new rules
In the spring, the federal government finalized regulations requiring millions of people who receive Medicaid benefits to prove they're working, volunteering, or going to school to keep their coverage.
asserted
they → finalize → coverage
States have until January to begin those checks.
asserted
States → have → checks
Montana, Arkansas, and Nebraska have already started implementing them.
asserted
Montana → start → them
The Trump administration's federal work requirements exempt certain groups of people: those with disabilities, those older than 64, pregnant people and Native Americans, among others.
asserted
requirements → exempt → others
To receive an exemption, anyone without a clear-cut qualification — such as through their age or disability status — will have to prove they're too sick to work.
asserted
they → receive → status
But the administration decided that being homeless isn't a medical condition and can't count as an automatic out from having to meet the new requirements.
asserted
being → decide → requirements
Many conservative policymakers support work requirements, and some states have attempted to implement such rules for years.
asserted
states → support → years
At least four states — Montana, Arizona, Kentucky and Utah — previously proposed policies that included homelessness as an exemption.
asserted
that → propose → exemption
But federal officials have said that's not allowed.
asserted
that → say → ?
In an email to KFF Health News, the Centers for Medicare & Medicaid Services declined to provide a comment on the record.
asserted
Centers → decline → record
But the agency confirmed that states must stick to the federal government's list of exemptions.
asserted
states → confirm → exemptions
Homelessness in the U.S. has increased by 27% from 2013 to 2025, according to data from the Department of Housing and Urban Development.
uncertain
Homelessness → increase → Development
Many, like Pugh, qualified for Medicaid, though the number of enrollees who are homeless is difficult to measure.
asserted
who → qualify → enrollees
In 2023, 55% of patients who received medical or behavioral health services through one of the nation's roughly 300 Health Care for the Homeless programs were enrolled in Medicaid.
asserted
who → receive → Medicaid
Jennifer Tolbert, deputy director of KFF's Program on Medicaid and the Uninsured, said the federal regulations are a lot stricter than many states had expected, even those on board with work requirements.
asserted
states → say → requirements
(KFF is a health information nonprofit that includes KFF Health News.)
asserted
that → include → News
"It took everyone by surprise," Tolbert said.
asserted
Tolbert → take → surprise
Mehmet Oz, who leads CMS, touted the regulations as a "path to prosperity" during a press conference in June.
asserted
who → lead → June
"We need to get people to try to work," Oz said.
asserted
Oz → need → ?
In June, 25 mostly Democratic-led states sued the Trump administration over the regulations, arguing the medical frailty standard would be too hard for enrollees to meet — and for states to assess.
asserted
states → lead → regulations
The work requirements are projected to increase the number of uninsured people nationwide by more than 5 million by 2034, according to the Congressional Budget Office.
uncertain
requirements → project → Office
Most states will begin to implement the Medicaid work requirements in January 2027.
asserted
states → begin → January
Montana plans to begin booting Medicaid enrollees from coverage in October 2026 if they can't prove they're in compliance with the work requirement.
asserted
they → plan → requirement
"My Medicaid is still active, but when are they gonna cut that off from me?" Pugh said.
asserted
Pugh → go → me
"I can't get employed.
asserted
I → employ → ?
How am I supposed to survive?"
asserted
I → suppose → ?
The differences between the states' and federal government's exemption lists don't end with people who are homeless.
asserted
who → end → people
In Montana, lawmakers also planned to excuse people fleeing domestic violence and caregivers of hospitalized family members — two other groups left off the federal exemption list.
asserted
lawmakers → plan → list
…and 31 more, not listed.
