Trump’s Medicaid work requirements have an unwelcome surprise for some states and patients

STAT News – Wednesday, June 3, 2026
By Tara Bannow, Chelsea Cirruzzo, and Daniel Payne

Medicaid leaders and advocates say they’re shocked by the Trump administration’s harsh directives for implementing Medicaid work requirements, which they say mark a pivot from how federal officials had characterized their plans just weeks ago.

Much of the conversation around the nearly 400-page rule that the Centers for Medicare and Medicaid Services released Monday afternoon centers on one of the ways that people can be exempted from work requirements: medical frailty. Getting that exemption will be more difficult than most people had expected, meaning that more sick and disabled people are likely to lose their Medicaid coverage.

“This is where we’ll see large and harmful coverage losses,” said Benjamin Sommers, an economics professor at the Harvard T. H. Chan School of Public Health. “This is a population that has high medical needs and is at major risk for harm if they lose coverage. That is the headline implication of the new rule.”

President Trump’s 2025 tax cut law imposed broad work requirements on the Medicaid program for the first time. Monday’s guidance offers the most detail yet about how the law will change the Medicaid program, which serves nearly 70 million people. The shifts will have substantial impacts on patients’ ability to get coverage — and on the political messaging in the coming elections.

Generally, the requirement that people work, engage in community service, or pursue education or training to qualify for Medicaid applies to adults who receive Medicaid via the Affordable Care Act’s coverage expansion.

In a March analysis, the Urban Institute projected that between 3 million and 7 million fewer people would be enrolled in Medicaid expansion coverage on average in 2028 due to work requirements alone. That’s in addition to about 2 million to 3.1 million people who will lose coverage because of requirements that they prove eligibility more frequently. Altogether, about a quarter to half of people facing work requirements will lose Medicaid, Urban estimated.

CMS’s complicated process for medical frailty likely won’t help. The agency created a two-step standard for medical frailty: A person must have a serious medical condition, and they must show that the condition impairs their ability to work.

In other instances, states have used a one-step standard, automatically defining people with certain conditions to be medically frail.

Using the more complicated standard creates more work for Medicaid beneficiaries, clinicians, and states, and upends planning work that state health officials had been doing.

“Patients managing serious chronic conditions, mental and behavioral health challenges, substance use disorders, cancer, and other complex health needs should not be forced to prove their inability to work in order to maintain access to the care and treatment they rely on,” said Amanda Pears Kelly, CEO of Advocates for Community Health, which represents community health centers.

Many state Medicaid leaders had planned on using the one-step definition, in large part because it’s the one CMS officials had signaled they intended to use in weekly meetings with states, said Kinda Serafi, a partner at Manatt Health who’s helping states implement work requirements.

Many states had been compiling lists of diagnosis codes they could pull from people’s Medicaid records to automatically deem them medically frail. Those won’t work anymore

Over the past two weeks, CMS abruptly canceled those meetings because of “potential policy changes,” Serafi said.

“There was never a discussion about whether the ability to work would be tied to the medical frailty definition, and the reason for that is because it’s simply not the standard in the H.R. 1 statute,” Serafi said, referring to the One Big Beautiful Bill Act, which contains the Medicaid work requirements.

CMS did not respond to a request for comment on Serafi’s characterization of those meetings.

CMS is leaving the precise definition of medical frailty up to states, so the exact details of how people will prove they are too sick to work will vary based on where they live.

The agency is calling on states to use data to make the determination as much as possible, though it’s unclear what state data could prove someone’s inability to work, Serafi said. Plus, that data can’t be more than a year old.

More than likely, doctors and other providers will be responsible for signing paperwork that says their patients’ conditions impair their ability to meet the work requirements. That’ll create new headaches for already overburdened clinicians—and it may be challenging for Medicaid patients to get the necessary paperwork completed, Spencer Perlman, an analyst at Veda Partners, wrote in a note to clients.

Providers are already overwhelmed, and adding more paperwork will only make things worse, said Harvard’s Sommers.

“It is not a realistic and successful strategy to expect that doctors and nurses are going to fill out the paperwork to keep people on Medicaid,” he said. “It’s not going to work.”

New Hampshire also relied on providers certifying people’s inability to work in its short-lived Medicaid work requirement program, but the Urban Institute found that providers often weren’t comfortable signing the forms or declined because they weren’t familiar with or disagreed with the program.

The other curveball is that Medicaid beneficiaries will only be able to self-attest that they meet the medical frailty exemption and other exemptions to the work requirements in the program’s first year. Starting Jan. 1, 2028, states will need documentation that proves people not only have the conditions, but that they impair their ability to meet the requirements.

CMS Administrator Mehmet Oz defended the rule, saying it’s part of larger reforms required to save the program from being bankrupted, he alleged, from fraud.

“I’m here because I love Medicaid,” he said at a White House press briefing Tuesday.

The fact that H.R. 1 does not mention employment in its description of medical frailty likely sets up CMS for a legal challenge, because its rule adds requirements that weren’t in the original legislation, Sommers said.

The Legal Action Center, which advocates for people with disabilities and substance use disorders as well as formerly incarcerated people, said CMS is exceeding its authority in narrowing the medically frail exemption “in ways that are not supported by the statute and that directly contradict Congress’s intent to protect vulnerable individuals in need of medical care from losing coverage.”

Work requirements and eligibility verification will require “substantial updates to eligibility systems, coordination across agencies, and sustained member outreach efforts,” Arizona’s Medicaid agency said in a statement, noting the “significant operational challenges” that the requirements pose.

The California Department of Health Care Services said in a statement before the rule that CMS may need to approve “good-faith waiver requests” should requirements create disruptions to state Medicaid programs. The state is reviewing the rules to determine whether it will seek a waiver.

Hospitals and other health providers are also considering the implications of the rule — and what they may be able to do about it.

America’s Essential Hospitals, a group that represents safety-net hospitals, said in a statement that the rule “goes beyond what Congress intended” in its writing of the law, saying it looked forward to working with CMS to “identify less burdensome approaches.”

Ann Greiner, president and CEO of the Primary Care Collaborative, said in a statement the policy would “further imperil access to high-quality primary care” and “undermine stability of practices across the nation.”

The groups did not respond to questions about whether they were considering legal actions.

Lobbyists and associations representing providers have already begun considering how they might roll back some parts of H.R. 1 that required changes such as work requirements, two people familiar with the efforts told STAT. Should Democrats regain control of Congress in the midterms, new opportunities to change the legislation could open up — especially as some Republicans expressed remorse for parts of the law after passing it.

But even if Democrats take both chambers of Congress, they would almost certainly need Trump’s signature to change one of his biggest legislative wins.

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