No way to implement Medicaid work requirements without being cruel, expert says

The federal Centers for Medicare and Medicaid Services this month released new rules for work requirements for recipients of Medicaid coverage. They generally require non-pregnant adults between the ages of 19 and 64 to work at least 80 hours per month; the rules start on Jan. 1, 2027.

Julia Métraux said the requirements go farther than many states had expected and may result in more Medicaid recipients losing their health care coverage. It also means states are working to figure out how to implement the new rules before the end of the year.

Métraux is Mother Jones’ disability reporter; she spoke with The Show more about this, and they started with how we got here, in terms of these new rules and potential cuts in Medicaid enrollment.

Julia Métraux

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Handout

Full conversation

JULIA MÉTRAUX: As part of Trump’s One Big Beautiful Bill, states, which is a majority of states, including Arizona, that have expanded Medicaid to people who are low income, they would have to implement work requirements.

And so, this is part of nearly a trillion dollars’ worth of Medicaid cuts that are going to happen over the following decade, well including the decade we’re in, and essentially, because there’s so much of a paperwork burden, people are going to be kicked off, and the states are in federal government are going to save money just out of people losing Medicaid.

MARK BRODIE: OK, so when you talk about paperwork requirements, what kinds of things will enrollees have to do that maybe they haven’t had to do up until now?

JULIA MÉTRAUX: Yeah, so there was a big surprise on June 1 that Centers for Medicare and Medicaid Services dropped, and it’s definitely not painting like hardworking staffers at that agency in a bad light, but there were essentially, what we were expecting is that there might be some exemptions for people on Medicaid with certain conditions to be able to qualify more easily but for Medicaid work requirement exemption.

And I have to say, most people on Medicaid do work, but there’s now, no matter what your condition is and you’re on Medicaid, you have to prove you’re not able to work. The first year they’re going to allow for self-attestation, but the year after, there is going to be paperwork required by doctors to fill out.

MARK BRODIE: So is the fear then then that folks who legitimately have conditions that preclude them from working will lose Medicaid, or people who already are working, who are on Medicaid, might also lose their coverage?

JULIA MÉTRAUX: It’s both. And also, a lot of people with health conditions might not identify as being disabled. Many do work, and so they can very well be working 40 hours a week at a minimum wage job or 20 hours per week, depending on their experience, and have Medicaid as their means of healthcare.

And because of, yeah, this paperwork burden, they could potentially risk losing it. And also, because not everyone has easy access to a doctor, whether or not they have clear health issues, and that means that not everyone has as someone to fill out the forms.

MARK BRODIE: And for enrollees who do work, and you mentioned most of them do already, what kind of new requirements will they have in terms of trying to keep their coverage?

JULIA MÉTRAUX: It’s just going to be a lot of paperwork burden. And when people are met with the need to just fill out this paperwork every six months, people are going to drop off.

MARK BRODIE: So how are states trying to prepare for this?

JULIA MÉTRAUX: Yeah, so as I mentioned, there were surprise rules on June 1. Essentially, there was already a mad dash.

I would also like to highlight that Nebraska did voluntarily start their Medicaid work requirement rules on May 1. They have to go back to the drawing board because they had a list of conditions where people can more easily qualify for exemptions, but now they’re not allowed to do that because CMS came down with the final rule on June 1, which was literally the last day that they could implement the, introduce the final rule based on their timeline.

There’s still time for open comment, so there’s a chance that this won’t be as strict in the finalized rule, but it’s a wait-and-see game.

MARK BRODIE: Is there a sense as to why these rules were a surprise, why they seemed to maybe be a little more strict than what the the bill that Congress passed and the president signed actually required?

JULIA MÉTRAUX: Yeah, so Jennifer Wagner, as mentioned in my article, from the Center on Budget and Policy Priorities, told me that she’s heard that this came from the White House as a last-minute adjustment to what was being introduced.

States did not see this coming. This was a huge surprise, and there’s already, there’s no way to implement Medicaid work requirements without being cruel. There’s just not enough time between now and January 1 for states who are trying, I guess, their best to not kick people off Medicaid to really go back to the drawing board and create new systems.

MARK BRODIE: Are there estimates as to how many people might lose their coverage once these rules go into effect?

JULIA MÉTRAUX: Yeah, so the Urban Institute came out with an estimate earlier this year that they’re predicting between 4.9 and 10.1 million fewer people would be enrolled in Medicaid by 2028 as a result of work requirements and more frequent eligibility checks. So, it’s a huge range, but it’s likely because they made this more strict, it’s likely going to be on the higher end.

MARK BRODIE: And what kind of impact are providers saying that this might have on them, you know, the the doctors and nurses and PAs who treat Medicaid patients?

JULIA MÉTRAUX: Yeah, of course, I think we all know if you have a health issue and like, for example, dealt with prior authorization or something like that, you know paperwork takes time. And so, it’s also very much an administrative burden on healthcare workers to be able to keep up. And of course, healthcare providers don’t want their patients to be losing health insurance.

MARK BRODIE: Well so, as you mentioned, there’s a a comment period, and, you know, these don’t go into effect till the beginning of the new year. What will you be watching for and looking at between now and then to maybe try to get a sense of of what’s going on and what the ultimate impact might be?

JULIA MÉTRAUX: Yeah, it’s hard to tell exactly what the impact will be in each state before we know, just like with the Affordable Care Act enhanced tax credits expiring, we just didn’t know until people signed up for that.

One thing that I’m looking for is how states individually respond, and we don’t know if they’re going to be able to create new verification systems because they really were not planning for CMS to drop a rule that like, for example, let’s just say what Nebraska had in place, someone with sickle cell disease. If they had sickle cell disease and they are already on Medicaid via the work expansion, then they can more easily qualify for uh work exemptions. But now, there’s a much harder process, and that’s going to just kick sick people off Medicaid.

A year and a half is not a lot of time to implement Medicaid work requirements. Experts were already saying this, and now there’s like around six months to implement a new system.

MARK BRODIE: All right, that is Julia Métraux, a reporter at Mother Jones covering disability. Julia, thanks so much, I appreciate it.

JULIA MÉTRAUX: Thank you.

EDITOR'S NOTE: Due to an editing error, this story has been updated to correctly attribute the headline.