10M could lose Medicaid due to work requirements, more frequent eligibility checks, study finds

Dive Brief:

• Between 5 million and 10 million people could lose Medicaid coverage in 2028 due to work requirements and more frequent eligibility checks mandated under the “Big Beautiful Bill” passed last year, according to an analysis by the Urban Institute and Robert Wood Johnson Foundation. 
• Two million to 3.1 million enrollees could lose coverage because states will have to redetermine their eligibility every six months, instead of annually. And between 3 million and 7 million could lose Medicaid due to policies that require many beneficiaries to log work, education or volunteer hours to stay enrolled. 
• Some beneficiaries who should meet the work requirement could lose their insurance anyway. Between 19% and 37% of those who already work could be disenrolled due to challenges documenting their compliance, researchers wrote. 

Dive Insight: 

The sweeping tax and policy law, signed by President Donald Trump in July, includes historic policy changes for the safety-net insurance, which covers some 76 million people across the country alongside its sister program for children. 

One of the most significant shifts is the addition of work requirements, which require many adults who received Medicaid through the Affordable Care Act’s expansion to report 80 hours of work, education or volunteer hours each month to stay enrolled. Additionally, states will have to check eligibility for expansion enrollees every six months instead of annually. 

However, states have some flexibility in determining how their work requirement is implemented, like how they define medical frailty and other exemptions and what documentation for compliance is required.

So the researchers determined the impact of the Medicaid policy changes based on high, medium and low mitigation efforts on the part of states. For example, high mitigation would include extensive automatic data-matching to determine eligibility and compliance with work requirements and broader definitions of medical frailty.

In comparison, low mitigation would include less automatic data matching that would require enrollees to do more work to verify compliance and narrower definitions of exemptions. 

Still, Medicaid expansion enrollment will decline across states in 2028 across all scenarios, according to the study. 

Enrollment would be 8.3 million in the low mitigation scenario, 10.5 million with a medium level of protections and 13.5 million in the high mitigation plan. Without the policy changes, expansion enrollment would be 18.4 million.

“Millions will go without Medicaid under work requirements and six-month redeterminations in the One Big Beautiful Bill Act, even with robust efforts to mitigate coverage losses,” Matthew Buettgens, senior fellow at the Urban Institute, said in a statement. “This will include many who are meeting or exempt from work requirements but have difficulty submitting the necessary paperwork.”

Some groups may face more significant coverage losses. For example, automatically verifying income from self-employment is more challenging, so 30% to 73% of self-employed enrollees subject to the work mandate could lose Medicaid coverage. 

And enrollees who care for people with disabilities are supposed to be exempt from work requirements, but states could also struggle to automatically confirm their status, according to the research. Medicaid expansion enrollment could fall by 19% to 52% among those who live with a family member with a disability.