One in five employed Medicaid enrollees at risk

Clinical takeaway: Working patients on Medicaid may still lose insurance in the new year if they don't meet rigorous reporting requirements or their hours run short or fluctuate. Watch for lapsed prescriptions, missed follow-up, and churn among low-wage workers. 

Most adults enrolled through Medicaid expansion will need to document at least 80 hours per month of work, schooling, or community engagement to stay on the program starting in 2027. The mandate, enacted under last year's budget reconciliation law, is expected to shrink enrollment enough to supply the largest share of the law's nearly $1 trillion in Medicaid cuts over a decade. For practices with sizable Medicaid panels, the question is less whether patients will fall off the rolls than which ones, and how many will be people with jobs. 

Disenrollment forecasting so far has centered on difficulties with work documentation. When Arkansas piloted work requirements in 2018, more than 18,000 people lost Medicaid within months, many unaware the rules existed. That experience built a consensus that administrative burden, not joblessness, would drive the losses. But it left a second question largely unexamined: whether low-wage work itself reliably produces 80 documentable hours a month. A new cross-sectional analysis takes up that question and finds that for a substantial share of working enrollees, the answer is no. 

Among adults plausibly eligible for Medicaid expansion and potentially subject to the new requirements, two-thirds were in the labor force, and those with jobs averaged more than 36 usual hours per week, close to full time. Yet roughly one in five, or 19.8%, of working enrollees could fall short of compliance on hours alone. Regardless of potential issues with documentation, enrollees could fail on hours in two ways: 13.6% usually worked within five hours of the 20-hour weekly minimum, and 7.6% reported schedules that swung more than five hours week to week. The two groups barely overlap. Fewer than 2% of working enrollees faced both problems, so each failure mode captures a mostly separate set of patients. 

Women had a 22% higher probability of falling short than men, and married enrollees an 18% lower probability than unmarried ones. Black and Hispanic enrollees carried lower risk than White enrollees, and risk declined as education rose. Exposure also varied substantially by state, both in how many enrollees work and in how their hours pattern against the threshold. 

The researchers analyzed 2023 to 2025 Current Population Survey data on adults 18 to 64 who were plausibly eligible for Medicaid expansion, drawn from 40 expansion states and Washington, DC, after excluding Georgia and Wisconsin as partial expansions. The sample comprised 19,476 observations, weighted to represent more than 16 million people annually.

Implementation now shifts to the states, which must build reporting systems before the deadline and may adopt the requirements sooner. Several plan to require multiple months of documented compliance before enrollment, a design the authors note would make these estimates conservative, since applicants with inconsistent hours would need to clear the bar repeatedly before coverage begins. Exemptions exist, including for parents of children 13 and younger and for people with a documented disability, but hinge on how states verify them, and hours lost to an unrecognized health condition or an unpredictable schedule qualify for none. 

"These results show that the ideological narrative of Medicaid recipients just needing to pull themselves up by their bootstraps does not consider the precarious employment and other real-world barriers that often prevent them from maintaining stable work over time," says Paul Shafer, PhD, associate professor of health law, policy and management at Boston University School of Public Health. "These new work requirements are going to be tougher to fulfill for people with less education, part-time jobs or gig work, who have less control over their hours, and those who have substantial health concerns that may not rise to the level of a documentable disability." 

Source: Shafer PR, et al. (2026 Aug 28) JAMA Health Forum. Medicaid Work-Reporting Requirements Under HR 1 and Insufficient or Inconsistent Work Hours