8M Medicaid Enrollees Risk Coverage Loss Under Work Mandate, Study Finds

More than 8 million people will be at risk of losing their Medicaid coverage once the Medicaid work requirement passed as part of last year’s reconciliation bill is fully implemented by the states, a study found.

Among a population of 16.5 million Medicaid beneficiaries ages 19 to 64, 50.4% of enrollees, or 8.3 million, would be at risk of disenrollment because they worked too few hours, Rishi Wadhera, MD, of the Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center in Boston, and colleagues reported in a study published in Annals of Internal Medicine.

“The findings should give states pause,” Wadhera said in an email to MedPage Today. “A core assumption behind work requirements is that most nonworking enrollees are able-bodied and simply need an incentive to work. Our data challenge that directly — the majority of those at risk have functional limitations that would make compliance genuinely difficult, yet they don’t meet formal disability criteria that would exempt them.”

Under the so-called “community engagement” requirements that are part of H.R. 1 — the reconciliation bill passed by Congress in July — Medicaid recipients are required to demonstrate at least 80 hours of engagement per month in employment; participation in a work program, such as job training; enrollment in an educational program (at least half time); community service activities; or a combination of these activities. The requirements take effect Jan. 1, 2027; they apply only to the 40 states (and the District of Columbia) that expanded the Medicaid program under the Affordable Care Act.

In a previous study Wadhera and colleagues conducted to see how Georgia’s implementation of its Medicaid work requirement program was faring, the researchers found that the program did not increase insurance coverage or employment relative to neighboring states that did not expand Medicaid. Georgia’s program has faced criticism over the high administrative costs.

“Our Georgia study was a natural experiment — we evaluated what actually happened when work requirements were implemented in one state, and found no meaningful gains in insurance coverage or employment,” Wadhera said. “This new study takes a complementary but forward-looking approach: with H.R. 1 now proposing to extend work requirements nationally to all Medicaid enrollees, we wanted to understand who is actually at risk of losing coverage.”

The answer was “striking,” he said, noting that more than half of those who would lose coverage “have significant functional impairments across physical, neuropsychological, and independent living domains. Together, the two studies tell a consistent story … Work requirements don’t achieve their stated goals, and they put vulnerable people at serious risk.”

To perform the study, the authors pooled data from the 2022-2023 Medical Expenditure Panel Survey (MEPS), a nationally representative survey that contains information on insurance coverage, employment, and health-related functional limitations. The authors excluded anyone meeting the law’s exemption criteria: beneficiaries who are receiving Supplemental Security Income, dually enrolled in Medicare, a caretaker for dependents younger than 14 years, not working due to attending school, or self-identified as Native American.

Enrollees whom the authors considered as being at risk of disenrollment included those who self-reported unemployment or working less than 20 hours per week (approximately 80 hours per month) and did not otherwise meet exemption criteria.

Wadhera said he was surprised by the magnitude of the possible disenrollment. “We expected to find elevated rates of functional impairment among those at risk, but the gaps were larger than anticipated,” he said. “Poor physical health was three times more common among those at risk of disenrollment compared to those meeting work requirements (32.7% vs 10.9%). Poor mental health was also substantially higher. What’s particularly concerning is that these are people falling into a gray zone — too impaired to easily comply, but not sick enough to qualify for formal disability exemptions. That’s a policy gap with real human consequences.”

Limitations of the study included that outcomes were self-reported and could be subject to recall bias and that certain work hour requirement exemptions — including pregnancy and participation in substance use treatment programs — couldn’t be accounted for because MEPS does not capture these variables. MEPS also does not reliably distinguish between adults attending school full-time or part-time, so part-time students who would not have been exempt may have been excluded, the authors explained.

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