In the early hours of the morning on May 22, the House of Representatives passed a sweeping reconciliation bill that threatens one of the foundational supports of Washington’s health care system: Apple Health, our state’s Medicaid program. The legislation, passed by a single vote, proposes stringent “work requirements” for “able-bodied” adults, which House Republicans praise as an attempt to combat fraud with a “moral component,” though the federal government’s own numbers demonstrate that fraud in this important safety net program is minimal, and almost always committed by providers and not patients. Equally troubling, the bill asserts a fundamental misunderstanding of the consequences of restricting access: Even if you or your family never uses Apple Health, these changes will affect you.

When people lose Medicaid coverage, they still need health care. People without health insurance often postpone treatment until their conditions become too serious to ignore, and are then forced to seek care in emergency rooms at significantly higher costs. Before the expansion of Medicaid eligibility allowed by the Affordable Care Act, hospitals caring for patients who didn’t have health insurance would be left to eat the costs — which in turn inflated the costs of care for people who were insured. Washington hospitals already function on extremely thin (or negative) operating margins, and for facilities already struggling, Apple Health is a crucial source of revenue. We have a saying in health care — “no margin, no mission” — and despite the best intentions of health systems providing care for everyone who needs it, absent the financial solvency that caring for insured patients provides, hospitals will suffer. Washington hospitals have faced closures and layoffs due to financial strain, notably in rural parts of the state. Further reductions in Medicaid reimbursement would make this much worse, causing more facilities to shut down. And when your hospital or clinic closes, it doesn’t matter what insurance you have — you’ll need to get your care somewhere else.

One in 10 Washingtonians are employed in the health care workforce. Closure of hospitals and clinics means substantial job losses, hurting local economies and exacerbating unemployment. The ripple effects reach local businesses, housing markets and community stability, impacting every Washingtonian, regardless of reliance on Medicaid. These proposed cuts threaten the integrity of health care services throughout our state, and rural communities in Central and Eastern Washington, where access to care is already in jeopardy, would be disproportionately affected. Without Medicaid funds, hospitals will struggle, if not fail, leaving residents with limited access to emergency or specialty care. Washington already has the fewest hospital beds per capita of any U.S. state; we simply cannot afford another hospital closure.

The bill’s proposed work requirements are particularly misguided: The evidence demonstrates that such requirements don’t work. The House bill defines “able-bodied” adults as those 19 to 55 without a documented disability or dependents, a narrow definition that will exclude many low-income Washingtonians who work inconsistent hours, care for aging relatives or struggle with undiagnosed mental or physical health issues, resulting in the loss of coverage for well-intentioned people who simply don’t meet the bill’s rigid criteria. In 2018, Arkansas became the first state to implement work requirements, and rather than increasing employment, it led to large coverage losses due to administrative burdens and confusion. More than half of the people losing Medicaid reported serious problems paying off medical debt and were forced to delay care and medications because of cost. And, since federal dollars flow into our state to help fund Apple Health — over $20 billion in fiscal year 2024, accounting for seven out of every 10 Apple Health dollars spent — every eligible beneficiary lost means fewer federal matching funds for health care in our state.

Washington stands to experience the largest estimated Medicaid enrollment loss nationally — with up to one in three Apple Health beneficiaries losing coverage by 2034. To offset the loss in federal funding, Washington would need to consider measures such as increasing state taxes, reducing spending on other programs like education or implementing cuts within Apple Health itself. These changes could have profound effects on our state’s health care infrastructure and our collective well-being — regardless of what health insurance we have. Washingtonians must recognize the broader implications of these Medicaid cuts, and demand that these changes not make their way into law. Protecting Medicaid is not merely about safeguarding health care for the vulnerable; it’s about maintaining a stable, effective health care system for all of us, ensuring hospitals remain open, care remains accessible and communities thrive.

Neil Jay Sehgal Ph.D., MPH, is an associate professor of Health Systems and Population Health and the Austin Ross Endowed Chair In Health Administration at the University of Washington School of Public Health.