Working, But Not Enough to Keep Medicaid

Last summer, President Trump and Congress passed H.R. 1, more commonly known as the One Big Beautiful Bill Act. It made major changes to Medicaid, including requiring that most recipients prove they are working to be eligible for benefits. We are now on the cusp of these work reporting requirements, also referred to as “community engagement” requirements, taking effect nationally. They are projected to be the largest source of Medicaid savings under the law, cutting $326 billion in costs over 10 years. However, the requirement will likely result in over 5 million people losing their coverage even though many of them already work.

Starting no later than January 1, 2027, adults enrolled in Medicaid as a result of its expansion under the Affordable Care Act (i.e., not qualifying for Medicaid through any of the traditional eligibility categories) must complete and document their work or engagement activities. They can satisfy the requirements in several ways. One is through hours, completing at least 80 hours per month of relevant activities, like paid or unpaid work, community service, or training. Another is by making at least the equivalent income of 80 hours per month at minimum wage. They can also be enrolled at least half-time in school to maintain benefits.

Crucially, there are several exemptions to Medicaid work reporting requirements, including for those who are pregnant or postpartum, parents (of children under age 14), caregivers for a dependent with a disability, and those who are disabled themselves or medically frail.

Medical frailty, in particular, is a hot topic in the policy community due to controversial rules released by the Centers for Medicare and Medicaid Services in June. They would require states, and potentially physicians, to consider not just frailty itself in determining whether to exempt people from work reporting requirements, but also whether the ability to work is impacted. States were not expecting the latter requirement and have been scrambling to adapt their plans for implementation as a result.

President Trump and Congress chose to increase these administrative burdens despite strong support among Americans for lowering them.

States are required to inform Medicaid enrollees by this fall about these new work reporting requirements. But it’s not clear how well-informed people who receive Medicaid are about the looming changes. We are concerned that millions will lose Medicaid due to difficulties navigating new administrative processes and paperwork.

We are particularly concerned that many enrollees might fall through the cracks due to the nature of their work. Our team recently published a study in JAMA Health Forum, looking at how many may lose coverage due to insufficient or inconsistent work.

Our interest in this topic was personal—stemming from our co-author Dave Anderson’s teenage daughter, whose part-time employer was canceling shifts with little notice. This led us to wonder how such a lack of control over work shifts could endanger Medicaid coverage under these new rules. We were also curious who, as in what demographic groups, are most likely to be at risk of non-compliance with work reporting requirements due to their work hours.

We analyzed Census Bureau data from the Current Population Survey for 2023 through 2025 to gain insight into what we might expect in 2027. These data capture demographics, health insurance coverage, and employment, which we used to examine those who will likely be subject to these work reporting requirements.

Average hours worked per week were near full-time (35.1 hours). Yet, we found that about 1 in 5 (19.8%) who are working were at risk of non-compliance with the forthcoming work reporting requirements. About two-thirds of this was due to being near the hours threshold, while about one-third was due to irregular hours.

Millions of Americans will grapple with confusion over these new rules, more paperwork that has to be completed more frequently, and worsening access to care.

Single women may be at particularly high risk once these rules take effect. We found that women face a 22% higher risk of non-compliance, while anyone who is married has an 18% lower risk. Similarly, people who have not graduated from high school will face a greater risk of falling out of compliance than those with more education.

Hourly work schedules are usually controlled by employers. Employees often have little say over when and how much they are able to work at a part-time job. These risks pile on top of the stress caused by having to gather relevant documents and complete confusing paperwork more frequently just to maintain Medicaid coverage. Through H.R. 1, President Trump and Congress chose to increase these administrative burdens despite strong support among Americans for lowering them.

Over half of American workers are paid on an hourly basis, so these changes threaten the health of many. Lower-income part-time workers generally don’t have access to employer benefits. This means that Medicaid might be their only option for health insurance, even if they are cobbling together multiple jobs and working full-time hours.

All of this paints a grim picture for Medicaid heading into 2027, when millions of Americans will grapple with confusion over these new rules, more paperwork that has to be completed more frequently, and worsening access to care.

This piece is in partnership with the Medicaid Policy Lab and the Politics and Health Lab at Boston University School of Public Health. The views expressed here are the authors’ own and do not necessarily represent the views of Public Health Post or Boston University School of Public Health.