High Disease Burden Among At-Risk Medicaid Beneficiaries Under New Work Requirements
A new wave of Medicaid policy changes is raising concerns among public health researchers, especially after a recent study revealed just how medically vulnerable many beneficiaries are. The study, conducted by Yale School of Medicine researchers and published in JAMA, takes a close look at adults who could lose Medicaid coverage under H.R. 1, the law signed on July 4 that introduces nationwide work requirements for certain Medicaid enrollees. What the researchers found is striking: more than 40% of the roughly 5 million people at risk have three or more chronic health conditions, and adults between 50 and 64 appear to be the most medically fragile group.
H.R. 1 will require Medicaid recipients who aren’t exempt to meet 80 hours per month of work, volunteering, schooling, or job-training activities starting January 1, 2027. While exemptions exist for individuals who are pregnant, caring for dependent children, or considered medically frail, the real-world challenge lies in how states define medical frailty and how beneficiaries navigate the administrative process to prove they qualify. Researchers say these barriers alone can push otherwise eligible people out of the program.
Using data from the National Health and Nutrition Examination Survey (NHANES), which collects extensive clinical and occupational information from a nationally representative sample, researchers were able to identify Medicaid beneficiaries who are not exempt but do not meet the new work requirements. According to the analysis, about two-thirds of adults at risk of losing coverage are women, and 41% live with at least three chronic conditions, including issues such as hypertension, arthritis, depression, obesity, and dyslipidemia. More than half of individuals in this group take one to four prescription medications, and a significant minority rely on multiple medications to manage complex health needs.
Among adults aged 50 to 64, the numbers become even more concerning. In this age group, 66% have at least three chronic medical conditions, 62% take between one and four prescriptions, and approximately 20% take five or more medications. These statistics point to a population with substantial care needs—people who benefit heavily from continuous Medicaid coverage and who may struggle to find or maintain work hours that meet the new threshold.
Interestingly, most adults who fall short of the requirement aren’t avoiding work altogether. Many are already working, but their schedules or physical limitations prevent them from reaching the 80-hour monthly benchmark. Others are actively searching for work. Despite this, they remain at risk of losing coverage solely because they cannot meet or document the required activity levels.
A look back at previous state-level attempts to introduce Medicaid work requirements adds context to the debate. In 2018, Arkansas became the first state to implement similar rules. The program was short-lived, halted by a federal judge the following year, but its impact was studied closely. Research found that the work requirements did not improve employment levels. What they did cause, however, were significant drops in coverage and declines in access to care—even among people who were technically working enough hours or should have been exempt. Much of the loss stemmed not from ineligibility but from the complexity of reporting systems and confusion around compliance.
Administrative hurdles are a major point of concern in the new national policy as well. The process of regularly proving eligibility—submitting documents, verifying work hours, and navigating state systems—can be burdensome. Researchers note that many individuals lose Medicaid not because they fail to meet requirements, but because they fail to complete paperwork correctly or on time. These procedural losses contribute to gaps in care that can worsen chronic illnesses, increase emergency-care use, and lead to higher long-term healthcare costs.
The study also highlights the complicated issue of determining who is medically frail. The federal government allows states to create their own definitions. However, earlier research from Yale found that many states’ criteria underestimate medical limitations and exclude people who clearly struggle with daily functioning or work capacity. Because older Medicaid recipients have a particularly high prevalence of chronic disease, the authors suggest that states consider expanding the medically frail category to include individuals aged 50 to 64. Doing so could prevent substantial coverage loss among a group that already relies heavily on sustained medical care.
There’s also a financial argument embedded in these findings. If individuals in their 50s and early 60s lose Medicaid and go without treatment for chronic conditions, Medicare may ultimately shoulder the burden once they turn 65. Untreated or poorly managed health issues can become significantly costlier, meaning that reducing Medicaid rolls now could drive up federal spending later. This possibility adds an economic layer to the public health implications of the new work requirements.
As states prepare to implement H.R. 1, each will face decisions about exemptions, reporting systems, and definitions of medical frailty. These choices will determine how many people ultimately lose coverage and how sharply health outcomes shift. The authors of the study emphasize that while policymakers may intend to promote employment or reduce program costs, the health realities of at-risk beneficiaries must be part of the equation. With such a high burden of disease documented, the consequences of losing Medicaid coverage could be severe and widespread.
To give readers more context, it’s important to understand how Medicaid work requirements fit into the broader landscape of U.S. healthcare policy. Medicaid is the largest public health insurance program in the country, covering low-income children and adults, people with disabilities, and older adults who need long-term care. Work requirements have been debated for years, with proponents arguing that they encourage employment and personal responsibility, and critics warning that they erect barriers that disproportionately hurt vulnerable populations.
Evidence so far leans heavily toward the latter concern. Studies on past work-requirement programs show that they often fail to increase employment and instead increase the number of uninsured people. People with chronic illnesses, unstable work schedules, cognitive limitations, or caregiving responsibilities are especially affected. Moreover, the individuals impacted are often those who use Medicaid the most efficiently—regular primary care users who prevent costly complications. Removing them from coverage can unintentionally raise healthcare spending rather than lower it.
The findings from Yale’s latest analysis add important data to an already heated policy conversation. The study paints a detailed picture of the people most likely to lose Medicaid due to the new rules: predominantly women, many in middle age, managing multiple chronic health issues, and already engaged in work or job-seeking efforts. With work requirements scheduled to take effect in 2027, states and federal policymakers have time to shape implementation. Whether they do so in a way that protects high-needs patients remains an open question.
Research Paper:
Clinical Characteristics of Adults at Risk of Medicaid Disenrollment Due to HR 1 Work Requirements — JAMA
https://doi.org/10.1001/jama.2025.16533
