Commenting on Medicaid Work Requirements
ATTN: There is one more week to submit comments on the proposed rules on Medicaid Work Requirements. This June, CMS announced new rules that would make health coverage continuity even harder for 20 million Americans. These rules are around the community engagement activities required for retaining Medicaid coverage, and the guidelines for who is exempt from them. These rules are being released with limited time for states to adopt them, and with limited time to integrate updates based on public comment. Public comments are due July 31st, and these rules are meant to be in place by January 1, 2027. In summary, here are the main areas AAHD is concerned about:
Medical Frailty Exemption
The proposed Medicaid rules allow for some people with disabilities and serious medical conditions to claim an exemption from work requirements. However, claiming this exemption would require a person to show that they are unable to work.
The proposed rules could harm disabled people who do work, who might only be able to work limited hours in a month based on their current health status and capacity. Forcing people to complete 80 hours of work-related activities each month would negatively impact these individuals, putting them at risk of coverage loss on a monthly basis.
In the medical frailty definition under HR1, states originally planned to exempt people who had relevant disabilities or health conditions, including people with low vision, substance use disorder, mental health conditions, physical or intellectual disabilities affecting daily living, or complex medical conditions. Under the proposed CMS rule, these conditions alone would not be enough to meet the exemption. For those claiming the exemption, they would be required to provide documentation on their inability to work. This paperwork would likely need to come from a doctor. For those who are currently uninsured, it might be impossible for them to furnish the required paperwork, unless they have current and relevant medical documentation. This is an additional burden on enrollees. Paperwork would need to be updated every time a person renews their coverage, meaning a person would need an updated medical letter as often as quarterly. Having a relevant diagnosis, even for a life-long condition, would not be enough to claim the exemption. States have filed a legal challenge to the medical frailty exemption definition, based on the additional risk it presents for enrollees who might lose health care, worsening their health. People with conditions like diabetes, HIV/AIDS, cancer, or mental health challenges will be the most in need of clear guidance on how to retain their coverage through these requirements.
The Compliance Burden on States
States will be required to handle the ongoing administrative work needed to process work requirement paperwork and exemption eligibility. With a January 2027 implementation deadline, states have been preparing for work requirements without federal guidance. Many have already updated their renewal and application forms prior to the rules being released. The new rules will force them to update their prior communications with enrollees, with only seven months left to the deadline. While enrollees will be able to self-attest to their need for an exemption from work requirements until 2028, states are still burdened with creating the proper work requirements tracking systems for the start of 2027. States are also concerned that these rules do not properly indicate how to determine a person is unable to work.
Strain on Health Care Providers
In reporting from KFF Health News, doctors have also indicated confusion about how to provide documentation determining someone’s ability to work. There is no standard assessment they can readily use. Asking doctors to make this determination could also strain their relationship with their patients. Some doctors and medical practices may choose not to accept Medicaid patients moving forward due to the administrative burden of new work requirements, further impacting access to care for many. Making doctors responsible for providing additional medical documentation will further cut into their standard patient care.
Based on analysis of the rules’ Regulatory Impact Analysis, the Center on Budget and Policy Priorities (CBPP) outlines how these work requirements would not actually deliver on their goal to promote work. Research has shown that Medicaid work requirements have lead to up to 33% of enrollees becoming uninsured. Instead of promoting the continuous coverage that helps people stay healthy to work, work requirements are often the cause of disenrollment and coverage loss. These requirements are shown to increase risk of early death, low health status, and higher rates of medical debt. Leighton Ku from the Milken Institute School of Public Health at George Washington University affirms these concerns in a recent commentary, claiming that CMS is misleading the public on the benefit of work requirements. They cite evidence that employment rates do not go up with work requirements, and question whether enough jobs are available for the 5 million individuals who may need to secure work to retain coverage. Addressing the issue of unemployment is even more complicated:
“Simply imposing work requirements is a short-sighted and fundamentally flawed strategy for addressing problems of unemployment among low-income Americans. There are complex social and structural barriers that impede employment — including limited education, literacy and job skills, health and behavioral difficulties, problematic job histories (e.g., incarceration), transportation problems, caretaking responsibilities and racial/ethnic discrimination, as well as limited job opportunities. Medicaid and SNAP benefits were designed to reduce hardship among needy Americans because of these intractable social and economic challenges.“
Analysis from the Commonwealth Fund showed that the loss of $160 billion in critical funds gutted under HR1 would have a larger ripple effect on the economy. They estimate $200 billion in lost productivity in states, especially in health care. This would affect as many as 1.65 million jobs.
Reminder: Individual advocates and organizations are encouraged to share a public comment on these proposed rules through July 31, 2026. Submit your comment through the Federal Register.
The United States of Care has launched a research program to study the experiences of Medicaid enrollees affected by the new work requirements. This study will follow enrollees in Idaho, Missouri, North Carolina, Pennsylvania, and West Virginia. Stay tuned for updates on this longitudinal research effort.
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