Introduction of Work Requirements to Medicaid Enrollment Could Destabilize Health: William Schpero, PhD, MPhil, MPH

The One Big Beautiful Bill Act (OBBBA) introduced a new aspect of enrolling or renewing Medicaid coverage across the nation, as those living in Medicaid expansion states will need to prove at least twice per year that they are meeting the 80-hour-per-month work requirement. William Schpero, PhD, MPhil, MPH, assistant professor of Population Health Sciences at Weill Cornell Medicine, spoke about how this will affect adults and children across the country.

This transcript has been lightly edited.

The OBBBA included changes to Medicaid enrollment, including adjusting work requirements to stay on Medicaid. What are the biggest changes in the work requirements to stay on Medicaid?

The OBBBA introduces a federally mandated work requirement in Medicaid for the first time. Specifically, adults enrolled under the Affordable Care Act’s expansion of Medicaid eligibility will have to demonstrate they are working or participating in other qualifying forms of community engagement (eg, job training or education) at least 80 hours a month in order to maintain their eligibility for Medicaid.

How does this change in work requirements affect Medicaid enrollment, including the process of applying for Medicaid?

Individuals subject to the work requirement will have to demonstrate compliance at both the time of initial enrollment and then again at least every 6 months during the period they are enrolled in Medicaid. The Congressional Budget Office has estimated that work requirements will lead about 5.3 million people to lose their Medicaid coverage by 2034, largely because of the administrative barriers associated with maintaining compliance.

Who stands to be the most affected by these changes? Are there exceptions to this ruling?

The new work requirement directly affects adults enrolled under the Affordable Care Act’s expansion of Medicaid eligibility. Certain individuals are exempt, including parents of young children, people who are pregnant or postpartum, and people who qualify as “medically frail,” among others.

Should there be a reduction in individuals enrolled in Medicaid, what would the effect be on hospitals in areas with more lower-income residents/more residents enrolled in Medicaid?

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. 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.

Is there an effect of this change in Medicaid enrollment that is going under the radar when looking at the impact it will have?

Even though the OBBBA work requirements target adults, there is strong evidence that health coverage and access to care among adults and children are linked. Prior research suggests that coverage losses among adults could introduce greater instability in coverage and harm health outcomes among children.