Between 4.9 and 10.1 million fewer people could be enrolled in Medicaid by 2028, according to the Urban Institute. H. Rick Bamman/Zuma
On Monday, the Centers for Medicare and Medicaid Services released its interim final rule on Medicaid work requirements, mandating that everyone who seeks Medicaid support has to prove they are unable to work to a greater extent, even if they have already been diagnosed with a debilitating condition like sickle cell disease—and even if they are already on Medicaid.
Federal Medicaid work requirements are being implemented as part of President Trump’s so-called One Big Beautiful Bill, a budget and spending bill which is also cutting nearly a trillion dollars from Medicaid’s budget over the next decade.
In states with Medicaid expansion, an Affordable Care Act provision that allows more low-income people to access Medicaid, the legislation mandated that work requirements be implemented, but didn’t resolve certain details of how and who would be targeted—questions the Department of Health and Human Services has now answered in the most restrictive possible way. The Urban Institute estimates that between 4.9 and 10.1 million fewer people could be enrolled in Medicaid by 2028 as a result of work requirements and more frequent eligibility checks. The interim final rule is likely to yield a figure at the high end of that estimate. Medicaid work requirements have to be implemented in all states with Medicaid expansion by January 1, 2027, though some Republican-led states have opted to do so ahead of schedule.
“Congress compelled states to impose Medicaid work requirements on the expansion population,” said University of Pittsburgh health policy and management professor Miranda Yaver, “but it wasn’t entirely clear from the legislation to what extent states’ hands were going to be tied…there were a lot of open questions about how much discretion there would have.”
Under the interim final rule, people with certain conditions who are already on Medicaid will no longer be automatically considered “medically frail,” a classification that exempts them from work requirements; they must provide further proof, beyond their diagnosis, that they are “greatly impaired” from working. The new federal rule is notably stricter than what was implemented in Nebraska, a GOP-dominated state that voluntarily enacted work requirements eight months before the deadline—but which at least retained a list of conditions considered automatically exempt from work requirements for those on Medicaid.
State officials were blindsided by this medical frailty definition outlined in the new federal rule, which was never brought up in discussions between states and the federal government, Jennifer Wagner, the Center on Budget and Policy Priorities’ director of Medicaid eligibility and enrollment, told me.
“We have heard that this was driven more by the White House,” Wagner said. “I don’t think it was CMS intentionally misleading states.”
While the federal interim rule is harsh, it is not final: there is a 60-day public comment period, after which states have until the end of the calendar year to implement (or, in Nebraska’s case, modify) their Medicaid work requirements.
“It’s going to be very costly in terms of time as well as money,” Wagner said, “and, realistically, states are not going to be able to do this accurately by January 1.”
There is no way to implement Medicaid work requirements without disabled and chronically ill people losing their access to the program, despite the claims of Republican politicians like House Speaker Mike Johnson (R–La.).
“There are going to be so many disabled people and chronically ill people who lose access to their health care and other kinds of supports that Medicaid provides,” said Maria Town, the President and CEO of the American Association of People with Disabilities.
Town is also extremely concerned that Medicaid-supported employment for disabled people is not considered to be meaningful “community engagement,” another stipulation for Medicaid coverage under the new rule. “It’s just a way of saying that disabled people’s labor shouldn’t be compensated,” Town told me.
The new administrative burdens will push people off of Medicaid, as when Medicaid work requirements were implemented in Arkansas during the first Trump administration, leading to 18,000 people losing Medicaid coverage in the state.
“People who had lost Medicaid benefits were worse off—they were more likely to have medical debt and have delayed important healthcare due to concerns about cost,” University of Colorado, Boulder economics professor Chloe East said in an interview.
Yaver, of the University of Pittsburgh, is also concerned that places that serve more Medicaid patients, like federally qualified health centers, will not be able to keep up with paperwork requirements to prove medical frailty.
“Writing attestations of medical frailty would almost assuredly fall under the umbrella of non-billable hours,” Yaver told me, “and this is going to be a large share of their patient population.”
Not only do Medicaid work requirements not increase employment, according to multiple studies, but a majority of adults on Medicaid already work.
“It’s hard not to think that the cruelty of the policy is the point,” East said. “Adding work requirements to Medicaid is part of a massive shift in our safety net in this country under this administration to make it as small and hard to access as possible.”
