5 Groups at Highest Risk of Losing Medicaid Coverage Under OBBBA

Between 4.9 million and 10.1 million people enrolled in Medicaid expansion are projected to lose coverage in 2028 under the work requirements and 6-month eligibility redeterminations in the One Big Beautiful Bill Act (OBBBA), according to a new analysis by researchers at the Urban Institute with support from the Robert Wood Johnson Foundation.¹ The range reflects 3 implementation scenarios depending on how aggressively states use automatic data-matching and broad exemption definitions to protect eligible enrollees.

As part of OBBBA, lawmakers introduced a new provision to Medicaid eligibility: all people either enrolled in Medicaid or enrolling for the first time must verify their work status every 6 months.² The government requires that all of those on Medicaid have at least 80 activity hours per month unless they have a valid exemption.

What makes these new findings particularly striking is that coverage losses are projected even among people who are working, have qualifying health conditions, or should be exempt under the law's own criteria.¹

“Medicaid enrollees subject to this requirement will have to report their work activities to their state Medicaid program and figure out how to navigate the new reporting system,” Jonathan Oberlander, PhD, professor in the Department of Health Policy & Management at the University of North Carolina at Chapel Hill, explained to The American Journal of Managed Care® (AJMC®).² “Since the budget law requires states to redetermine eligibility at least twice a year, this process will occur multiple times a year. This will constitute a new administrative barrier to enrollment in Medicaid.”

The problem isn't always eligibility; it's verification.¹ States must be able to automatically confirm compliance or exemption using available data, and for several key populations, those data are difficult or impossible to access quickly.

Here are 5 groups the analysis identifies as facing the highest risk of losing coverage despite potentially qualifying to keep it.

1. Adults Aged 50 to 64 Years

Older working-age adults face some of the steepest projected losses in the analysis, with enrollment declines ranging from 30% under high mitigation to 65% under low mitigation. That translates to between 1.2 million and 2.6 million people in this age range losing coverage.

Two factors converge here. Adults aged 50 to 64 are less likely than younger enrollees to be parents of children 13 years or younger, which is the primary automatic exemption pathway under OBBBA. They are also more likely to have health conditions that limit their ability to work, yet those conditions may not appear in the specific data systems states use to identify medical frailty. Even under a broader medical frailty definition that includes common chronic conditions like diabetes and hypertension, projected losses for this group decline only modestly. The 6-month redetermination requirement alone drives a significant share of this group's losses regardless of how work requirements are implemented.

2. Self-Employed Workers

Self-employed individuals face the highest projected enrollment losses of any subgroup in the analysis, ranging from 30% to 73% and representing between 405,000 and nearly 1 million people.

The core problem is data availability. State quarterly wage databases cover more than 95% of traditional W-2 employment, making it relatively straightforward to verify that salaried workers meet the income threshold equivalent to 80 hours per month at the federal minimum wage. Self-employment income does not appear in those databases. Gig workers, freelancers, and independent contractors would largely need to manually document their income, and based on prior state experience with work requirements in Arkansas and New Hampshire, the analysis projects that between 65% and 87% of those required to verify manually will fail to do so successfully. Some states are piloting consent-based tools to access gig platform and payroll data, but these are not expected to be widely operational by the January 2027 implementation deadline.

3. Students

Students enrolled at least half-time in higher education or career and technical programs are explicitly compliant with OBBBA's work requirements. Yet the analysis projects enrollment losses among students ranging from 21% under high mitigation to 56% under low mitigation, affecting as many as 2 million people.

The gap between compliance and verified compliance is the issue. Part-time enrollment status is not consistently collected on Medicaid applications, and data sources that could confirm student status, including the National Student Clearinghouse and state university systems, are not yet integrated into most Medicaid eligibility systems. Under the low mitigation scenario, states are assumed to be unable to automatically identify students at all, requiring manual verification. Under the high mitigation scenario, states are assumed to identify only half of students automatically. CMS guidance and state investment in data-sharing agreements with educational institutions could help, but the timeline before implementation is short.

4. Family Caregivers of People With Disabilities

OBBBA explicitly requires states to exempt family caregivers of people with disabilities from work requirements. Despite this mandate, the analysis projects enrollment losses among those living with a disabled family member of between 19% and 52%, affecting between 351,000 and 979,000 people.

Automatic verification of caregiving status is extremely difficult with existing data systems. The law does not define "disabled" for this provision, leaving states to resolve significant ambiguity on their own. Without the ability to automatically deem caregivers exempt, many will be required to manually document their status, and, based on prior state experience, a substantial share will fail to navigate that process successfully, not because they do not qualify, but because the administrative burden is too high.

5. People With Poor Health or Functional Limitations

The medical frailty exemption in OBBBA is intended to protect people with serious health conditions from losing coverage. In practice, the analysis finds that the exemption's reach will depend heavily on how states define medical frailty and what data they use to confirm it.

Under the baseline high mitigation scenario, enrollment declines among those reporting fair or poor health are projected at 23%, and declines among those with a functional limitation or work-limiting condition range from 16% to 17%. Under low mitigation, those figures climb to 59% and 62%, respectively. The report finds that adopting a broader medical frailty definition, one that includes common chronic conditions considered serious under other federal laws, such as the Family and Medical Leave Act, would reduce overall work requirement coverage losses from 3 million to 2.3 million under high mitigation. The CMS guidance expected by June 2026 will therefore carry significant clinical consequences for patients with ongoing prescriptions, specialist relationships, and chronic disease management needs.

The Bottom Line

A common thread runs through all 5 groups; the risk of losing Medicaid is not primarily a function of whether someone qualifies, but whether a state's data systems can confirm it automatically. The Urban Institute analysis is explicit that, even under the most robust implementation scenario it modeled, millions of qualifying enrollees will still lose coverage, and that number could double if states fall short on data infrastructure and the breadth of exemptions.

“A major concern is that projected coverage losses under the OBBBA work requirements will have severe effects on safety-net health care providers in both rural and urban areas that disproportionately care for low-income populations. These providers already face high levels of financial precarity and are at elevated risk of closure at baseline,” William Schpero, PhD, MPhil, MPH, assistant professor of population health sciences at Weill Cornell Medicine, said in an interview with AJMC.³ “Although the OBBBA includes a Rural Health Transformation Program that is designed to mitigate the financial effects of the bill for rural health care providers, it seems pretty clear that the size of the program ($50 billion) is quite small relative to the projected financial effects of the law.”

For managed care organizations and health systems serving Medicaid populations, these projections signal meaningful disruption to coverage continuity beginning as early as 2027.¹

References

1. Buettgens M, Karpman M, Haley JM, Carter J, Kenney GM. Projected reductions in Medicaid expansion enrollment under OBBBA's work requirements and six-month redeterminations: national and state estimates for 2028. Urban Institute. 2026. https://www.rwjf.org/en/insights/our-research/2026/03/millions-could-lose-health-coverage-due-to-new-rules.html
2. Bonavitacola J. Medicaid work requirements set to leave millions without insurance. AJMC. November 4, 2025. Accessed March 27, 2026. https://www.ajmc.com/view/medicaid-work-requirements-set-to-leave-millions-without-insurance
3. Bonavitacola J. Introduction of work requirements to Medicaid enrollment could destabilize health: William Schpero, PhD, MPhil, MPH. AJMC. November 8, 2025. Accessed March 27, 2026. https://www.ajmc.com/view/introduction-of-work-requirements-to-medicaid-enrollment-could-destabilize-health-william-schpero-phd-mphil-mph