A new rule by the Trump administration could make it even harder for millions of sick Americans to obtain or stay on Medicaid after work requirements start next year.
The work requirement was established last summer as part of Republicans’ major tax and domestic policy legislation, and requires poor adults without disabilities to prove they worked, volunteered or attended school at least 80 hours a month or lose their Medicaid eligibility. Congressional leaders have described it as an effort to reduce “waste, fraud and abuse” in the program.
At the time the law passed, the Congressional Budget Office estimated around five million people would become uninsured because of the work requirement, including many who were working but unable to handle the paperwork to prove it. Medicaid currently covers about 68 million Americans who are poor or disabled.
The law laid out a series of exceptions for vulnerable people, including a carveout for people who are “medically frail.”
But the law did not define that term clearly. Some experts had said it was a way to protect people whose health problems might worsen if they lost their health coverage, like those with cancer. In informal conversations with states in recent months, Medicaid officials had indicated they were embracing that approach.
But other experts recently urged the administration to view frailty as meaning too sick to work. That stricter interpretation was reflected in the final rule. It says people’s medical conditions must “significantly impair” their ability to meet the work requirement, language that is not in the statute itself.
“The exemption ensures that work expectations are directed to those who can participate and protecting those fully who cannot,” said Dan Brillman, who oversees Medicaid for the Trump administration.
The rule cites, as examples, that those who have H.I.V./AIDS, cancer or end-stage renal disease would not be exempt from reporting work hours unless their illness is serious enough to make it hard for them to work or volunteer.
The stricter rules may result in the loss of coverage for more Americans. The narrower definition of frail will make fewer people eligible for an exception. And studies have shown that even eligible people lose access to social welfare programs when they are required to report their work hours.
Groups representing patients with serious diseases criticized the new approach. “Congress promised that no cancer patients would lose their coverage under the One Big Beautiful Bill,” said Dr. Gwen Nichols, the chief medical officer at Blood Cancer United. “This rule undercuts that promise.”
Setting up work requirements is a major undertaking for state Medicaid programs. They have to build complex computer systems and train staff to help them evaluate who qualifies for each exception and who has worked the minimum number of hours.
States had expected that people with certain serious diagnoses would quality for the exception, and they had been developing ways to match applications with existing medical records to identify most such people automatically. Nebraska’s Medicaid program, which began enforcing a work requirement last month, developed a list of exempted conditions that is nearly 300 pages long. The state will now need to adjust.
Cindy Mann, who was the top Medicaid official in the Obama administration, said the new definition would be challenging for states to implement using existing data sources. “This is not a simple determination,” she said.
Other groups eligible for exceptions include pregnant women, the parents of young children, caregivers for disabled relatives, and people who have been recently hospitalized. The rule also narrowed an exception for people who live in an area with a declared national emergency, by adding a condition that the emergency must affect residents’ ability to work.
The new rule also explained how Americans would apply for an exemption from the Medicaid work requirement.
In 2027, Americans will be allowed to sign forms swearing they meet the requirements. After that, new Medicaid enrollees will have six months to gather the necessary records proving they qualify as medically frail.
“We’re forgiving, but we’re not foolish,” said Dr. Mehmet Oz, the administrator for the Center for Medicare and Medicaid Services, in a phone call with reporters.
The new rule encourages states to use automatic data systems to verify employment. But people without steady jobs at large companies may need to to submit records themselves at least once every six months.
Some details of the rule have come as a surprise for states. For months, state officials have been meeting regularly with Medicaid staff, who have been advising them verbally and with slide presentations.
But last month, one such meeting was abruptly canceled. A few days later, Mr. Brillman sent states an email telling them to disregard the previous advice.
“There are several areas where changes have been made to the preliminary policy previously shared,” he wrote, according to a copy of the email obtained by The New York Times.
Since Mr. Brillman sent his email, many state officials have been fretting about whether they will be able to comply with last-minute changes. On Friday, six Democratic governors sent a letter to top federal health officials asking the Trump administration to delay the implementation of work requirements if the federal government rescinded its previous guidance.
The administration has recently been highlighting efforts to reduce fraud in Medicaid. At a recent public appearance, Stephen Miller, a deputy chief of staff at the White House, suggested that federal programs that use “the honor system” have invited fraud.
Brian Blase, the president of the Paragon Health Institute, a health policy research group with strong ties to the Trump administration, applauded Monday’s rule for ensuring that applicants claiming health problems really have them.
“To succeed, these requirements must be effectively designed and enforced to minimize gaming and abuse,” he said in a statement, adding that he believes the rule “strikes the appropriate balance between necessary program integrity protections and accommodations for those who genuinely need assistance.”
Along with the new rule, the administration published an article Monday arguing that the Medicaid work requirement would lift at least 1.6 million Americans out of poverty, by encouraging more work and higher incomes. To support its analysis, staff members at the Department of Health and Human Services cited studies of work requirements in other social welfare programs. Not everyone who has studied those programs shares the authors’ view.
More specifically, the research on Medicaid has so far not supported the conclusion. Only one state that covered childless adults without disabilities has tried work requirements for Medicaid. In a 2018 pilot program in Arkansas, 18,000 people quickly lost coverage after failing to submit documentation proving their work status. A study found that the policy did not increase the number of eligible people who worked.
Margot Sanger-Katz is a reporter covering health care policy and public health for the Upshot section of The Times.
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