Least Healthy Medicaid Enrollees Face Highest Risk of Coverage Loss Under Work Requirements Expansion

About half of working-age adults enrolled in Medicaid, roughly 8.3 million people, would be at risk of losing coverage under a national expansion of Medicaid work requirements, and those most likely to lose coverage carry significantly greater physical, neuropsychological, and functional burdens than those who would meet the mandate, according to new research published today in Annals of Internal Medicine.¹

The study comes as the US Congress debates extending work requirements beyond the One Big Beautiful Bill Act (HR 1; OBBBA), signed into law in July 2025, which requires able-bodied adults in the 40 Medicaid expansion states to work or participate in qualifying activities for at least 80 hours per month. Proposals now gaining traction would apply that standard to all working-age beneficiaries nationwide.

Using 2022 to 2023 Medical Expenditure Panel Survey data, researchers from Beth Israel Deaconess Medical Center and Harvard T.H. Chan School of Public Health identified adults aged 19 to 64 years on Medicaid who did not meet HR 1 exemption criteria and worked fewer than 20 hours per week. That group totaled 8.3 million adults, or 50.4% of working-age enrollees, and one-third of them reported an illness or disability that limited their ability to work, despite not qualifying for a formal disability exemption.

Across all assessed functional domains, at-risk adults fared considerably worse than those meeting the work threshold. Severe physical impairment was nearly 3 times more common among at-risk beneficiaries (12.4% vs 4.5%), and moderate to severe neuropsychological impairment, encompassing cognitive difficulty, psychological distress, and social participation limitations, was more than 3 times as prevalent (12.5% vs 3.4%). Poor physical health was reported by 32.7% of the at-risk group compared with 10.9% of those meeting requirements, and poor mental health by 28.2% vs 19.5%.

“These impairments might not meet formal disability criteria but could compromise enrollees’ ability to adhere to work requirements, thereby increasing their risk of coverage loss,” the authors wrote.

Those concerns extend to the administrative demands of compliance. Jonathan Oberlander, PhD, of the University of North Carolina at Chapel Hill, warned that biannual work verification would create a new enrollment barrier even for people already working.² "Many Medicaid enrollees who work and are eligible for the program will nonetheless lose Medicaid coverage because of the administrative complexity and burden of these requirements," he told The American Journal of Managed Care^® (AJMC^®) for a November 2025 article.

The stakes of getting exemptions right are illustrated by a recent Urban Institute analysis, which projected that between 4.9 million and 10.1 million Medicaid expansion enrollees could lose coverage in 2028 under the OBBBA’s work requirements and 6-month redeterminations.³ The analysis found that coverage losses were substantial even among people who should qualify for exemptions, including adults aged 50 to 64 years, self-employed workers, students, family caregivers of people with disabilities, and those with poor health or functional limitations. The common thread across all 5 groups was not ineligibility, but rather the inability of state data systems to automatically confirm that eligibility.

Interestingly, previous research by Minal Patel, PhD, MPH, of the University of Michigan, found that Medicaid coverage helped unemployed enrollees return to work as their health improved, with employment nearly doubling among those who recovered after gaining coverage.² “By requiring work before providing the coverage that enables it, the policy risks reducing both coverage and employment, an outcome opposite its stated goal,” Patel told AJMC.

The new study extends prior estimates focused on HR 1's narrower expansion population.¹ The Congressional Budget Office projected roughly 5.1 million expansion enrollees could lose coverage under HR 1; a 2025 JAMA analysis put the figure at about 5 million. By looking at all working-age Medicaid beneficiaries, the new study arrives at the higher total of 8.3 million and adds granular health and functional data largely absent from prior projections.

Limitations include self-reported outcomes, inability to account for pregnancy or substance use treatment exemptions, and exclusion of institutionalized adults. The authors also note their estimates may be an upper bound, given overlap with the post–COVID-19 pandemic Medicaid unwinding period.

As Congress weighs a nationwide expansion of work requirements, the findings make a case that current exemption frameworks may not reach far enough and that the administrative burden of compliance could cost coverage for millions of people who would otherwise be eligible to keep it.

References

1. Vyas DA, Mein SA, Tale AP, Wadhera RK. Functional status of adults at risk of Medicaid disenrollment under national work requirements. Ann Intern Med. Published online March 31, 2026. doi:10.7326/ANNALS-25-04811
2. Bonavitacola J. Medicaid work requirements set to leave millions without insurance. AJMC. November 4, 2025. Accessed March 31, 2026. https://www.ajmc.com/view/medicaid-work-requirements-set-to-leave-millions-without-insurance
3. Grossi G. 5 groups at highest risk of losing Medicaid coverage under OBBBA. AJMC. March 27, 2026. Accessed March 31, 2026. https://www.ajmc.com/view/5-groups-at-highest-risk-of-losing-medicaid-coverage-under-obbba