Imagine you have no address, no alarm clock, no reliable internet connection, and no boss who will sign a timesheet. Now imagine the government telling you that you must prove you are working — or lose your healthcare. That is the situation facing hundreds of thousands of homeless people in the United States, now that federal Medicaid work requirements have been written into law without a clear exemption for people living on the streets. For years, conservative politicians and policy analysts argued that work requirements were never meant to punish the truly vulnerable.

People who are elderly, pregnant, disabled, or caring for young children would be protected, they said. The reassurance sounded reasonable. But when the federal government finally published its list of exemptions, advocates noticed something striking: homeless people were not on it. People who sleep in shelters, under bridges, or in cars — people who already face enormous daily obstacles — would still be required to log and report working hours in order to keep their Medicaid coverage.

The omission has alarmed health policy researchers on multiple continents. Scholars who have studied similar welfare-to-work experiments in Australia and the United Kingdom have warned that documentation requirements tend to hit the most chaotic and precarious lives the hardest. In those countries, people without fixed addresses were frequently cut from benefits not because they refused to comply, but because they simply could not navigate the paperwork. History, it seems, has a habit of repeating itself.