Trump covering health coverage for more people
Edited by Gaby Clark,
reviewed by Robert
Egan
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Up to 10 million people may lose Medicaid coverage in the
United States due in part to new work requirements and eligibility
redeterminations under the One Big Beautiful Bill Act (OBBBA), which mandates a
reduction of nearly $1 trillion in Medicaid spending over a decade.
While the administrative
burden associated with meeting and maintaining these work requirements
is expected to be the primary driver of disenrollment, a new study led by
researchers at Boston University School of Public Health (BUSPH) and the Arnold
School of Public Health at the University of South Carolina (Arnold School)
found that millions of Medicaid enrollees may lose their health coverage
because they are unable to achieve the required work hours.
Who is most at risk
Set to take effect nationwide on Jan. 1, 2027, the new
federal Medicaid work reporting rules require adults enrolled in the Affordable
Care Act's Medicaid expansion to show that they are working, volunteering,
enrolled in school and/or participating in job training for at least 80 hours
per month, with certain groups exempt. But the new study found that nearly 20%
of Medicaid-eligible adults living in states that expanded Medicaid are at risk
of noncompliance because they are unlikely to fulfill the minimum required
hours once the rules take effect. The findings are published in JAMA Health Forum.
Certain groups were more at risk of noncompliance than
others. Women had a 22% higher probability of having insufficient or
inconsistent work hours than men, while married Medicaid enrollees had an 18%
lower probability of noncompliance than unmarried enrollees.
Despite misconceptions by Medicaid work requirement proponents that able-bodied Medicaid recipients do not work, the study showed that more than 66% of applicable Medicaid recipients are in the labor force and, among that group, more than 85% worked more than 35 hours on average.
Unstable jobs, unstable eligibility
However, many working Medicaid recipients may experience
challenges that prevent them from completing 80 hours of work each month. Many
Medicaid recipients hold low-wage positions in the retail, hospitality, food
service, health care and agriculture industries, which often provide
inconsistent and unpredictable work hours and positions. These workers may also
encounter challenges with reliable transportation to and from
work, affordable and reliable child care, and unrecognized disabilities or
chronic health conditions that make it difficult for them to complete job tasks
week after week.
"These results show that the ideological narrative of
Medicaid recipients just needing to pull themselves up by their bootstraps does
not consider the precarious employment and other real-world barriers that often
prevent them from maintaining stable work over time," said study lead and
corresponding author Dr. Paul Shafer, associate professor of health law, policy
& management at BUSPH and codirector of the Boston University Medicaid
Policy Lab. "These new work requirements are going to be tougher to
fulfill for people with less education, part-time jobs or gig work, who have
less control over their hours, and those who have substantial health concerns
that may not rise to the level of a documentable disability."
Furthermore, he said, "ample evidence suggests supporting people through Medicaid actually
helps them to have stable
employment because their health is better managed. Without Medicaid
coverage, it is unlikely they will be able to meet both basic and critical
health needs."
State-by-state gaps emerge
For the study, the team used federal social and economic
data to examine employment among nonelderly adults plausibly eligible for
Medicaid in the 40 Medicaid expansion states and Washington, D.C., from
2023–2025. The researchers estimated the prevalence of adults at risk of
noncompliance because they were near the 20-hour-per-week threshold or reported
variable hours (both +/- 5 hours) within the last week compared with their
normal weekly hours.
They found that 19.8% of eligible Medicaid recipients were
in danger of not meeting the work requirements, with 13.6% near the minimum
hours threshold and 7.6% having highly inconsistent work hours. There were
substantial differences in both employment activity and the prevalence of
noncompliance across expansion states, spanning multiple regions. States such
as Connecticut, Ohio, Arkansas and Nevada had among the highest proportions of
people at risk of noncompliance due to insufficient work hours, while Massachusetts,
Wisconsin, Colorado and Washington were among the states with the highest
proportions of people at risk due to variable work hours.
"Work and community engagement requirements assume
Medicaid expansion-eligible individuals have predictable schedules that
translate into the same hours worked as scheduled," said study senior
author Dr. David Anderson, assistant professor in the Department of Health
Services Policy and Management at the Arnold School. "Our study shows that
this is not the case. People who are trying to meet these requirements are at
higher risk if they face short look-back periods and limited hardship exemptions."
Single mothers face a squeeze
Single mothers with high school-aged children may be among
the most affected groups, Shafer said.
"Parents are only exempt if their children have a
recognized disability or are under the age of 14, so single moms with older
children must meet and report these work requirements to remain eligible,"
he said.
In addition to differences based on education level, sex and
marital status, the researchers also observed racial and ethnic disparities in
risk of noncompliance: Eligible Black and Hispanic Medicaid recipients had a
lower risk than eligible white recipients. Those with higher education levels
also had a lower risk compared with individuals who held less than a high
school diploma.
Longer look-backs could widen barriers
The researchers also pointed out that these findings may be
conservative estimates, as several states are expected to determine Medicaid
eligibility based on multiple months of preemptive compliance prior to
enrollment.
"States must look back to the prior month for
compliance before the Medicaid application is filed, but they can look back as
far as three months," said study co-author Dr. Timothy Callaghan,
associate professor of health law, policy & management at BUSPH. "That
means that, in some states, individuals must demonstrate work over several
months to qualify for benefits. This will slow the access of newly employed
individuals to Medicaid benefits in these states and could lead to disparities
in Medicaid access for those with inconsistent work."
Publication details
Paul R. Shafer et al, Medicaid Work-Reporting Requirements
Under HR 1 and Insufficient or Inconsistent Work Hours, JAMA Health
Forum (2026). DOI:
10.1001/jamahealthforum.2026.2938
Journal information: JAMA Health Forum
