Medicaid work requirements threaten health coverage for millions

By Kate Gilliard, Senior Manager, Federal Policy and Regulatory Affairs
and Sahana Chakravartti, Regulatory Strategist

Millions of patients will lose the Medicaid health care coverage they rely on under a new work requirement rule that CMS is imposing on states.

While CMS is taking comments about this interim final rule through July 31 (and an AAFP Speak Out makes it easy for you to also tell your legislators what you think), you should know why the AAFP and other major physician organizations are deeply concerned about the Medicaid work requirements, also known as community engagement requirements. The One Big Beautiful Bill Act directed CMS to implement these requirements, but CMS has gone far beyond the statute’s provisions and proposes additionally restrictive provisions in its interim final rule.

What are the new Medicaid work requirements?

The rule will require most adult Medicaid enrollees to work, attend education programs or give community service for 80 hours a month, otherwise they risk losing their health care coverage. Certain individuals are exempt from these requirements, including pregnant or postpartum individuals, individuals with disabilities or medical frailty, and parents or caregivers of children under age 14 or people with disabilities. However, CMS uses a more restrictive definition of “medical frailty” than the statute. Under this rule, medical frailty will not be based solely on health status. Instead, it must also be shown to significantly limit a patient’s ability to meet the work requirements.

This shift will make it harder for patients to qualify for and document medical frailty while creating challenges for states that have begun developing eligibility criteria under a broader definition. The rule initially allows limited self-attestation for proof of fulfilling work requirements or securing exemption status, including medical frailty. However, starting in January 2028, states will be required to collect documentation for all exemptions.

States will have to implement the work requirements by Jan. 1, 2027, and some have already started enforcing the rule.

Millions of patients will lose Medicaid coverage

CMS estimates that 2.3 million people will lose Medicaid in just the first year of implementation, growing to 3.3 million people losing coverage by 2036.

These are some of your patients who most need comprehensive health care from family physicians. The Medicaid work requirements rule will make communities less healthy by causing eligible patients to lose access to affordable health care, while simultaneously increasing administrative burdens for patients, physicians and states.

Even worse, these massive coverage losses will come from an experiment that researchers have already found does not work. Less than a year after Arkansas implemented a similar work requirement to qualify for Medicaid in 2018:

Add your voice to protect Medicaid

The AAFP has long advocated for Medicaid coverage that allows your most vulnerable patients to afford health care. The program not only helps enrollees stay as healthy as possible; it also improves health care access for entire communities by funding an expanded primary care workforce.

You can bolster this advocacy by urging your legislators to stop CMS from implementing more restrictive Medicaid work requirements than intended in statute and other draconian cuts that hurt Medicaid programs, patients and physicians. Add your voice today.