Millions of Americans Could Lose Medicaid in 2027 — Here's Who Must Work 80 Hours a Month to Keep It

A new Medicaid rule could leave millions of Americans scrambling to prove they have worked enough hours to keep their health insurance in 2027. For some, the problem will not be finding a job. It will be getting enough predictable hours every month.

Starting 1 January 2027, certain adults covered through Medicaid expansion will have to demonstrate at least 80 hours a month of work or other qualifying activity to maintain eligibility. The requirement was created by the 2025 reconciliation law, known as the One Big Beautiful Bill Act.

The rule applies primarily to adults aged 19 to 64 who are covered through the Affordable Care Act's Medicaid expansion and meet the other eligibility conditions. Qualifying activities can include employment, community service, certain job-training programmes, and education. However, people will have the option to combine activities to reach the 80-hour threshold.

There are also exemptions and exclusions, including for certain caregivers, parents, and pregnant women. The precise rules and implementation can vary by state.

Before the bill was introduced, note that there was no federal work requirement, and states attempting to test work requirements needed to submit a waiver request to the Centers for Medicare & Medicaid Services.

More importantly, the changes will cut about $1 trillion from federal Medicaid spending over 10 years. The cuts are part of the Trump administration's efforts to offset the extension of tax cuts and to curtail spending and eliminate fraud.

Nearly 20% at Risk of Non-Compliance

A new study published in JAMA Health Forum found that 19.8% of potentially affected Medicaid-eligible adults in expansion states are at risk of non-compliance because of insufficient or inconsistent work hours. The researchers estimated this could affect 2 million people.

That does not mean one in five Medicaid recipients will automatically lose coverage. Instead, the research highlights how many people could struggle to satisfy the new requirement because their working hours are too low or unpredictable.

This threshold could be particularly important for people working in retail, hospitality, food service, healthcare, and agriculture, where shifts can be very dynamic.

Even people already working substantial hours may face difficulties if they cannot consistently document them.

David Anderson, a senior author of the study, said workers in low-wage jobs often have little control over their schedules and can lose hours through circumstances beyond their control.

Without health insurance, affected people are more likely to suffer from a lack of healthcare access, experience poorer health outcomes, and experience increased financial distress.

Retirees, Rural Workers, and Single Mothers Face Hurdles

The major health coverage changes could also create problems for people who have left the workforce.

Americans aged 50 to 64 who receive Medicaid after retiring could face a particularly difficult situation if they are required to return to work to maintain eligibility. Some may have left physically demanding jobs because of health problems or because they could no longer perform the work.

Rural residents could face another obstacle amid fewer available jobs and transportation difficulties. Elsewhere, gig workers and self-employed people may also have to navigate additional challenges proving their qualifying activity.

Lastly, women could face disproportionate difficulties, with the JAMA research finding they had a 22% higher likelihood than men of having insufficient or inconsistent work hours. Single mothers with older children could face the brunt of the new rules because not all parents qualify for the relevant exemptions.

The Stakes Are High

The Congressional Budget Office estimates the 2025 reconciliation law will reduce Medicaid enrolment by 12.9 million by 2034, while increasing the number of uninsured people by 7.5 million compared with previous projections. The estimate covers multiple Medicaid provisions, not just the work requirement.

For those affected by the new community-engagement rules, keeping Medicaid may therefore come down to something as simple, yet difficult, as proving 80 qualifying hours every month.

For workers whose schedules are controlled by an employer, seasonal demand, or the availability of local jobs, reaching that threshold may not always be entirely within their control.

'We're not trying to be alarmist, but there's a substantial number of people who will be losing coverage,' said Paul Shafer, the study's lead author.