New research suggests that about half of working-age Medicaid enrollees could be at risk of losing health coverage under a nationwide expansion of work requirements. The analysis also found that many of those at greatest risk report substantially higher levels of physical, mental, and functional impairment than beneficiaries who already meet the proposed employment threshold.
The findings arrive as policymakers continue debating whether work requirements introduced under the One Big Beautiful Bill Act should be extended beyond Medicaid expansion states. According to research published in Annals of Internal Medicine, the study adds new evidence about the health characteristics of people who may struggle to comply with the policy despite remaining eligible for coverage.
Researchers analyzed 2022 and 2023 Medical Expenditure Panel Survey data to estimate how many adults aged 19 to 64 would fall below the required 80 hours of monthly work or qualifying activities without meeting existing exemption criteria. The analysis focused on beneficiaries who worked fewer than 20 hours per week and did not qualify for exemptions outlined in the legislation.
Adults at Risk of Losing Coverage Reported Greater Physical and Mental Health Challenges
According to the study published in Annals of Internal Medicine, approximately 8.3 million adults, representing 50.4% of working-age Medicaid enrollees, would fall into the at-risk category under a nationwide application of the work requirement framework. Researchers also found that one-third of these individuals reported an illness or disability that limited their ability to work even though they did not qualify for a formal disability exemption.
The health differences between at-risk adults and those meeting the work threshold were consistent across multiple measures. Severe physical impairment was reported by 12.4% of adults at risk compared with 4.5% among those meeting the requirements. Moderate-to-severe neuropsychological impairment, including cognitive difficulties, psychological distress, and limitations in social participation, affected 12.5% of the at-risk group compared with 3.4% of those who met the threshold.
The study also found poorer self-reported health among individuals facing potential coverage loss. Poor physical health was reported by 32.7% of at-risk beneficiaries compared with 10.9% of those meeting the work requirement, while poor mental health affected 28.2% and 19.5%, respectively. According to the authors, these impairments may not satisfy formal disability standards but could make it more difficult for beneficiaries to comply with work requirements and maintain coverage.
Administrative Verification Remains a Central Concern
The study’s findings align with broader concerns about the administrative process required to verify eligibility. According to The American Journal of Managed Care, Jonathan Oberlander, PhD, said beneficiaries subject to the policy would have to repeatedly report work activities as states conduct eligibility redeterminations at least twice each year. He stated that many Medicaid enrollees who are working and remain eligible could still lose coverage because of the complexity of the reporting process.
Additional analysis from the Urban Institute projected that between 4.9 million and 10.1 million Medicaid expansion enrollees could lose coverage in 2028 under the work requirements and six-month eligibility redeterminations established by the One Big Beautiful Bill Act. According to the Urban Institute, projected coverage losses include adults aged 50 to 64, self-employed workers, students, family caregivers of people with disabilities, and individuals with poor health or functional limitations, largely because state data systems may not be able to automatically verify their eligibility for exemptions.
The authors of the Annals of Internal Medicine study noted several limitations, including reliance on self-reported data, the inability to account for pregnancy or substance use treatment exemptions, and the exclusion of institutionalized adults. They also stated that their estimates could represent an upper bound because the study period overlapped with the Medicaid unwinding that followed the COVID-19 public health emergency.
