By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy
On January 1st, 2027, Americans enrolled in state Medicaid programs will be required by federal law to work, enroll in half-time education, complete community service hours, or participate in a work program for 80 hours per month in order to maintain coverage (Centers for Medicare and Medicaid Services, 2026). While some exemptions exist, advocates worry that qualifying for those exemptions, reporting work or volunteer hours, and maintaining coverage will result in unacceptable coverage lapses for roughly 600,000 Americans (Altman, 2024).
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| Source: McCourt School of Public Policy at Georgetown University |
Make no mistake:
Work requirements for social safety programs are not designed to root out waste, fraud, or abuse; that has left many advocates asking if they are fundamentally and purposefully designed to create such high administrative burdens that poor Americans are forced off of the programs those implementing the work requirements openly hope to destroy (Ives-Rublee & Musheno, 2025).
Moreover, more than half of current Medicaid enrollees are unaware that work requirements are being implemented, despite state and federal efforts to inform them, and just over one-quarter of enrollees report hearing about them but were unsure of the details (Olsen, 2026).
And who, frankly, can blame them for being unaware?
Because of the nature of the Medicaid program—federally funded, but administered at the state level—getting a good grasp on what requirements are going to be implemented and where.
The Kaiser Family Foundation (KFF) has created a relatively comprehensive dashboard to track the implementation of the Medicaid changes enacted by the One Big, Beautiful Bill Act (OBBBA). The dashboard can be accessed using the following link:
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| Source: Kaiser Family Foundation |
With those issues established, let’s take some time to review what has advocates so concerned:
Medicaid Work Requirement Exemptions
The Centers for Medicare and Medicaid Services (CMS) has released some guidance regarding exemptions to the upcoming work requirements, listing the following categories of people as being exempt:
- Former foster care youth;
- American Indians and Alaska Natives;
- Parents, guardians, caretaker relatives, or family caregivers of a dependent child 13 years of age and under, or a disabled individual;
- Veterans with a total disability rating;
- Medically frail or otherwise have special medical needs that significantly impair their ability to comply with the requirement;
- Meet the TANF work requirements or are a member of a household receiving SNAP benefits and are not exempt from the SNAP work requirements;
- Participants in a drug or alcohol rehabilitation or treatment program;
- Inmates of a public institution; and
- Pregnant or eligible for postpartum coverage in their state.
States may also opt to provide additional short-term exemptions for hardship, including those who are:
- Receiving certain medical services such as inpatient hospital or nursing facility services;
- Residing in a county in which there is an emergency or disaster declared by the President;
- Residing in a county with a high unemployment rate; or
- Traveling outside of their community for an extended period of time for medical services for a serious or complex medical condition for themselves or their dependent (CMS, 2026)
According to The Commonwealth Fund:
H.R. 1’s criteria for medical frailty almost exactly parallel the Alternative Benefit Plan (ABP) definition. Both definitions must at least include people who meet Social Security Administration (SSA) disability criteria or have a substance use disorder, “disabling” mental disorder, “serious or complex” medical condition, or physical, intellectual, or developmental disability that “significantly impairs” their ability to perform an activity of daily living (Musumeci et al., 2025).
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| Source: The Commonwealth Fund |
As Musumeci et al. clarify, the SSA eligibility criteria do not incorporate the most recent developments in medicine or knowledge about disability, and those living with chronic conditions, including diabetes, heart failure, and lung disease, do not currently qualify as being “disabled” by the SSA, even though such chronic ailments can be wholly debilitating.
Tim Horn, Director of Medication Access at the National Alliance of State and Territorial AIDS Directors (NASTAD), openly stated at ADAP Advocacy’s recent Fireside Chat in Pittsburgh, Pennsylvania, that there are no exemptions for people living with HIV/AIDS (PLWHA), and that there is little clarity from states regarding whether or not self-attestation will continue to qualify as “proof of work.”
ADAP Advocacy always believes, but does not expect, that the Trump Administration should create specific exemptions for people living with chronic illnesses. The reality, however, is that we have come to expect only the worst from an administration whose members are openly hostile to the poor, the sick, the old, and the frail!
Disclaimer: All funders of the ADAP Advocacy Association are publicly listed on our website.
Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association; rather, they provide a neutral platform for the author to promote open, honest discussion of public health-related issues and updates.
References:
[1] Altman, D. (2024, December 17). Making Sense of Medicaid Work Requirements. Menlo Park, CA: KFF. https://www.kff.org/from-drew-altman/making-sense-of-medicaid-work-requirements/
[2] Centers for Medicare and Medicaid Services. (2027, June 01). Medicaid Community Engagement Requirement for Certain Individuals Interim Final Rule with Comment Period [CMS-2454-IFC]. Baltimore, MD: United States Department of Health and Human Services: Centers for Medicare and Medicaid Services: Newsroom: Fact Sheets. https://www.cms.gov/newsroom/fact-sheets/medicaid-community-engagement-requirement-certain-individuals-interim-final-rule-comment-period-cms
[3] Ives-Rublee, M. & Musheno, K. (2025, July 03). The Truth About the One Big Beautiful Bill Act’s Cuts to Medicaid and Medicare. Washington, DC: Center for American Progress: Article. https://www.americanprogress.org/article/the-truth-about-the-one-big-beautiful-bill-acts-cuts-to-medicaid-and-medicare/
[4] Musumeci, M., Rao, P., Crays, A., & Shachar, C. (2025, December 18). How Medical Frailty Exemption Policies Can Offer a Lifeline to People with Disabilities and Chronic Illnesses When Medicaid Work Requirements Are Implemented. New York, NY: The Commonwealth Fund: https://www.commonwealthfund.org/blog/2025/how-medical-frailty-exemption-policies-can-offer-lifeline-people-disabilities-and-chronic
[5] Olsen, E. (2026, June 08). Over half of Medicaid enrollees say they’re unaware of upcoming work requirements. Newton, MA: Healthcare Dive: News. https://www.healthcaredive.com/news/over-half-medicaid-enrollees-unaware-work-requirements-health-management-academy-survey/822228/
