In the early hours of Thursday morning, the U.S. House of Representatives passed the One Big Beautiful Bill Act after approving an amendment intended to mollify opponents to the bill, especially on the Republican side of the aisle.

The changes include moving up the rollout of federal work requirements for Medicaid, among other tax-related reforms. What remains unchanged in the bill are exceptions to the work requirement that ultimately might be advantageous to vulnerable behavioral health patients. 

The amendment to the bill now requires establishing work requirements as a condition of getting Medicaid, with certain populations exempted, by the end of 2026. Initially, it would have required states to make those work requirements effective by Jan. 1, 2029. 

The amendment potentially reveals compromises that House leadership made with Republican federal spending hawks to get them behind the bill after a few sided with Democrats to scuttle the One Big Beautiful Bill in committee last week. All Democrats and two Republicans opposed the bill in the final vote. It ultimately passed with a one-vote majority — the voting totals being 215-214.

At the beginning of the month, the White House released a proposed budget outlining President Donald Trump’s agenda. It included tens of billions of dollars in direct cuts to funding and other winnowing reforms related to health care and research.

The acceleration of the Medicaid work requirements brings a touchy measure meant to give states new grounds to reconsider members’ qualifications for Medicaid to reality. The potential impact of such a requirement is unclear. A previous analysis of Medicaid enrollees found that 64% of non-elderly adult Medicaid recipients work full-time or part-time. Only a small percentage would not be exempted by a health condition or other life circumstance. The same analysis found that state-level work requirements did not increase employment. Rather, they resulted in thousands of people losing coverage. 

The bill now heads to the U.S. Senate. Speaker of the House Mike Johnson (R-La.) said it’s his hope that the Senate changes the bill as little as possible. Any changes would require approval from the House. 

What are the work requirements about? 

The work requirements dictate that those on Medicaid must either work 80 hours a month, do 80 hours a month of “community service,” participate in a work program for 80 hours a month, be enrolled in an educational program part-time or be engaged in some combination of the four that totals 80 hours per month.

The mandatory exceptions for the work requirements apply to children, women who are pregnant or qualify for postpartum services as defined by Medicaid, those that qualify for Medicare (those aged 65 and older and those with specific medical conditions) or those who were recently incarcerated.

The mandatory exceptions also extend to “specified excluded individuals.” These include those who are classified as Native American according to the federal government, take care of someone who is disabled, veterans with disabilities and are medically frail.

Medically frail folks are defined as those being blind, “with a substance use disorder,” “with a disabling mental disorder,” with intellectual or developmental disabilities or with serious and complex medical conditions.

State plans may include exemptions for short-term hardship, including for members that have received inpatient hospital services or other residential care for physical, psychiatric or disability care; for residents of counties where an emergency has been declared by the president