Q: What challenges or unmet needs make this study important?
The One Big Beautiful Bill Act (H.R.1) introduces new work requirements for Medicaid beneficiaries, requiring adults to document at least 80 hours per month of work or community engagement to maintain coverage. Currently, these requirements apply only to adults who gained coverage through their states participating in Affordable Care Act Medicaid expansion, but proposals to extend work requirements to all Medicaid beneficiaries are gaining traction.
Supporters of these policies often characterize beneficiaries who are not working as “able-bodied” and argue that work requirements will incentivize employment. However, little is known about the functional health of Medicaid beneficiaries who are not currently meeting work requirements. Understanding the health and functional status of this population is critical for anticipating who may be at risk of losing coverage if work requirements are implemented nationwide.
Q: What central question(s) were you investigating?
In our study, we sought answers to three main questions:
- If Medicaid work requirements are implemented nationally, how many beneficiaries would be at risk of disenrollment due to insufficient work hours?
- Among adults on Medicaid who are not meeting work requirements, what is their level of functional impairment?
- How do their functional, physical and mental health outcomes compare with beneficiaries who meet work requirements?
Q: What methods or approach did you use?
We analyzed nationally representative data from the 2022–2023 Medical Expenditure Panel Survey (MEPS). Our study population included adults ages 19–64 enrolled in Medicaid who did not meet common exemptions from work requirement policies, including receiving Supplemental Security Income, dual enrollment in Medicare, caregiving for dependents younger than 14 years old, attending school or self-identifying as Native American.
We categorized adults as at risk of disenrollment if they reported being unemployed or working fewer than 20 hours per week. Adults not at risk of disenrollment were those working at least 20 hours per week, meeting the typical threshold used in proposed Medicaid work requirement policies.
Q: What did you find?
If work requirements were implemented nationally, approximately half of Medicaid beneficiaries—over 8 million adults—would be at risk of disenrollment because they work fewer than 20 hours per week.
Compared with beneficiaries who meet work requirements, those at risk of disenrollment had substantially higher levels of functional impairment across multiple domains, including physical functioning, neuropsychological functioning and independent living activities.
Adults at risk of disenrollment reported substantially worse health than those meeting work requirements. They were about three times as likely to report poor physical health and markedly more likely to report poor mental health, with more than 1 in 10 adults at risk of disenrollment experiencing both poor physical and mental health simultaneously.
Q: What are the real-world implications, particularly for patients?
Policy discussions around Medicaid work requirements often assume that beneficiaries who are not working are broadly able-bodied and capable of employment. Our findings challenge that assumption.
Many beneficiaries who do not meet work requirements appear to have substantial functional limitations including difficulties with physical functioning and independent living. These limitations may directly affect their ability to maintain consistent employment.
Because this group also experiences higher rates of poor physical and mental health, loss of Medicaid coverage could further exacerbate existing health needs. As a result, work requirements may disproportionately affect individuals with significant—but often unrecognized—health limitations.
Q: Were you surprised by any of the findings?
Although many beneficiaries in this group do not receive formal disability benefits, our findings suggest that a large proportion fall into a “gray zone” between full health and formal disability. These individuals may have meaningful functional limitations that are not captured by existing disability eligibility criteria.
As policymakers and states develop exemption criteria based on concepts such as “medical frailty,” our results highlight the importance of recognizing this hidden burden of functional impairment. Failure to account for these limitations could leave many beneficiaries caught in a double bind: too limited by their health to sustain work, yet falling outside of formal disability protections that would exempt them from work requirements. At the same time, the high rates of unmet physical and mental health needs in this population make the consequences of losing Medicaid particularly severe.
