Medicaid Work Requirements Expansion Threatens 8 Million Impaired Adults, Study Warns

Medicaid work requirements expansion could place health coverage at risk for more than 8 million adults with illnesses or functional impairments, according to a new peer-reviewed study that examined how stricter eligibility rules may affect working-age beneficiaries across the United States.

The findings, published in the Annals of Internal Medicine, analysed federal survey data collected between 2022 and 2023 and come as lawmakers continue debating broader work requirements for Medicaid recipients.

The proposal is linked to provisions in the One Big Beautiful Bill Act, which would require many Medicaid beneficiaries aged 19 to 64 to complete at least 80 hours of work, education, job training or other qualifying activities each month.

Beneficiaries who fail to meet those requirements and do not qualify for an exemption could lose Medicaid coverage despite remaining financially eligible for the programme.

Medicaid Work Requirements Expansion And Health Risks

Researchers estimated that 8.3 million adults, representing 50.4% of working-age Medicaid enrollees, would fall into an 'at-risk' category under a nationwide implementation of the proposed work requirements.

The study defined the group as adults working fewer than 20 hours per week who would not automatically qualify for one of the exemptions outlined in the legislation.

Among those identified as being at risk, approximately one in three reported an illness or disability that limited their ability to work but did not satisfy the legal definition required to receive a disability exemption.

The researchers said this finding suggests many beneficiaries experiencing significant health limitations could still be subject to work-reporting requirements.

Health differences between the at-risk population and beneficiaries already meeting the proposed work threshold were consistent across multiple measures.

Severe physical impairment was reported by 12.4% of at-risk adults compared with 4.5% among those already satisfying the work requirement.

Moderate to severe neuropsychological impairment, including cognitive difficulties and psychological distress, affected 12.5% of the at-risk group compared with 3.4% of beneficiaries meeting the employment threshold.

Self-reported health outcomes also differed substantially. Poor physical health was reported by 32.7% of at-risk adults, compared with 10.9% among those already meeting the work requirement. Poor mental health was reported by 28.2% of the at-risk group versus 19.5% among compliant beneficiaries.

The authors noted that the study identifies associations between health status and potential eligibility under the proposed policy but does not establish that the work requirements themselves would cause those health outcomes.

Administrative Requirements Could Also Affect Coverage

Researchers also highlighted the practical challenges involved in implementing work requirements.

Under the proposed framework, Medicaid recipients would need to regularly document employment or qualifying activities while states conduct eligibility redeterminations at least twice each year.

Health policy experts have warned that administrative reporting requirements could result in some eligible beneficiaries losing coverage because of paperwork or verification issues rather than failing to meet work expectations.

Jonathan Oberlander, a health policy scholar quoted by The American Journal of Managed Care, said some individuals could remain eligible under the rules but still lose coverage if they encounter difficulties completing required documentation or navigating state reporting systems.

Separate modelling by the Urban Institute estimates that between 4.9 million and 10.1 million Medicaid expansion enrollees could lose coverage by 2028 if work requirements and more frequent eligibility reviews are implemented nationally.

Those projections include several groups whose employment circumstances may be difficult to document consistently, including adults aged 50 to 64, students, self-employed workers and family caregivers.

Researchers noted that individuals with fluctuating work hours, irregular income or unpaid caregiving responsibilities may face additional challenges demonstrating continued eligibility under the proposed reporting system.

However, the authors also acknowledged several limitations to their analysis.

Some findings relied on self-reported survey responses, while certain exemption categories, including pregnancy and treatment for substance use disorders, could not be fully evaluated using the available data.

The study also excluded institutionalised adults and was conducted during the post-pandemic Medicaid eligibility 'unwinding,' a period in which many states were reassessing enrollee eligibility following the end of COVID-19 emergency protections.

The researchers said those factors could influence the overall estimates but do not change the broader finding that a substantial proportion of adults who could be affected by work requirements report significant physical, mental or cognitive health limitations.

The findings add to ongoing debate over whether Medicaid work requirements would primarily encourage employment or instead increase the number of eligible adults who lose health insurance because they are unable to satisfy or document the programme's reporting requirements.

As lawmakers continue considering changes to Medicaid eligibility rules, the study provides new evidence on the characteristics of beneficiaries who could be most affected by a nationwide expansion of work requirements.