Abstract
Background:
H.R.1 implemented Medicaid work requirements for beneficiaries in states participating in the Affordable Care Act, but Congressional policymakers are considering extending work requirements nationally to all Medicaid enrollees. However, little is known about Medicaid-enrolled adults at risk of disenrollment.
Objective:
To assess the functional status and overall health of adults at risk of Medicaid disenrollment under national work requirements
Design:
Cross-sectional study
Setting:
Medical Expenditure Panel Survey, 2022–2023
Participants:
Adults aged 19–64 years enrolled in Medicaid who did not meet common H.R.1 exemption criteria. We classified beneficiaries as at risk of disenrollment if they worked fewer than 20 hours per week.
Measurements:
Measures of functional impairment across physical, neuropsychological, and independent living domains, and composite measures of physical and mental health
Results:
The annual weighted population of Medicaid beneficiaries aged 19–64 years was 16.5 million (mean age: 40.5 years, 54.4% female). Among these enrollees, 50.4% or 8.3 million (SE ±0.5 million) would be at risk of disenrollment by working too few hours. Compared with beneficiaries meeting work requirements, those at risk of disenrollment reported higher levels of functional impairment across physical, neuropsychological, and independent living domains. Proportions with poor self-reported health were also higher among beneficiaries at risk of disenrollment than those reporting better health (poor physical health: 32.7% vs 10.9% and poor mental health: 28.2% vs 19.5%, respectively).
Limitation:
Self-reported measures, inability to capture all exemption criteria
Conclusions:
Under national Medicaid work requirements considered by Congress, half of all beneficiaries would be at risk of disenrollment even though they had greater functional impairment and poor health than those who were not at risk. These impairments might not meet formal disability criteria and could compromise these enrollees’ compliance with work requirements, thereby increasing their risk of coverage loss.
Introduction
The One Big Beautiful Bill Act (H.R.1), signed into law in July 2025, established Medicaid work requirements that mandate able-bodied adults to work or participate in qualifying activities for at least 80 hours per month to maintain coverage (1). These requirements currently only apply to adults in 40 states (and D.C.) who gained eligibility through Medicaid expansion under the Affordable Care Act (“expansion enrollees”). However, policy proposals to extend work requirements to all working-age Medicaid beneficiaries nationwide are now gaining momentum, raising concerns about the potential impact on coverage (2).
Although proponents of work requirements argue that many able-bodied Medicaid beneficiaries choose not to work (3,4), this is based on scant information about the functional status and health of this population. Prior state-level pilot programs of Medicaid work requirements have led to substantial coverage loss (5–7), underscoring the importance of examining the potential impact of applying work requirements nationwide. While most work exemption criteria are well defined, others are more ambiguous (8). In particular, exemptions based on “medical frailty” are largely subject to state interpretation, with recent analyses reporting wide variation in how states define frailty (9). This lack of consensus highlights the need for greater clarity regarding functional limitations and health status that may affect beneficiaries’ ability to meet work requirements.
This national study of potential consequences on Medicaid enrollment of extending Medicaid work requirements nationally had two objectives. First, we estimated the number of working-age adults with Medicaid coverage at risk of disenrollment. Second, we examined measures of functional status and overall physical and mental health among beneficiaries at risk of disenrollment.
Methods
Data and Sample Population
We pooled data from the 2022–2023 Medical Expenditure Panel Survey (MEPS), a nationally representative survey that captures detailed information on insurance coverage, employment, and health-related functional limitations. Our study population included adults aged 19 to 64 years enrolled in Medicaid. We first excluded those meeting the exemption criteria listed in H.R. 1 as identified in MEPS by the following: receiving Supplemental Security Income (SSI); dually enrolled in Medicare; caretaker for dependent(s) younger than 14 years old; not working due to attending school; or self-identified as Native American (Figure 1). We defined the Medicaid population at-risk of disenrollment when they did not meet the exemption criteria or self-reported unemployment or working fewer than 20 hours per week (≈80 hours/month).
Figure 1.
Flow Diagram of Study Population After Application of Work Requirement Exemption Criteria
1 All numbers represent unweighted sample size.
2 After applying the work requirement exemption criteria depicted, an additional 61 individuals were removed due to incomplete survey weights, arriving at our final unweighted sample size of n=2,140.
Primary Outcomes
The primary outcomes were self-reported measures of functional status across three domains: physical limitations, neuropsychological impairment, and independent living (Supplemental Table 1). Each domain comprised multiple survey items, and MEPS respondents answered each as a binary indicator of the presence or absence of a specific limitation. These functional status measures have correlated strongly with high health care utilization and spending, supporting their construct and predictive validity (10, 11).
Physical impairment was assessed using seven physical limitation indicators from the MEPS Health Status module, which capture difficulty performing common physical activities. These indicators included difficulty using fingers to grasp, reaching overhead, bending or stooping, standing for 20 minutes, walking 3 blocks, walking up 10 steps, and lifting 10 pounds. Each item was coded as present or absent and summed to create a physical functional limitation composite score ranging from 0 to 7. Consistent with established functional assessment frameworks (12, 13), composite scores were categorized to represent increasing severity of cumulative limitations as no impairment (0), mild impairment (1–2), moderate impairment (3–4), or severe impairment (≥5).
Neuropsychological impairment was assessed using three MEPS indicators that reflect cognitive, psychiatric, and participation-related limitations: cognitive limitation (difficulty remembering, concentrating, or making decisions), social participation limitations (limitations participating in social, recreational or family activities due to poor health), and severe psychological distress. Psychological distress was evaluated using the Kessler 6 (K6) scale, a validated six-item measure of psychological distress in the past thirty days. Consistent with prior literature, we defined the presence of psychological distress as a K6 score ≥13 (14). Each neuropsychological indicator was coded as present or absent and then summed to create a composite score ranging from 0 to 3, which was categorized as no impairment (0), mild impairment (1), or moderate to severe impairment (2–3).
Independent living impairment was assessed using MEPS indicators for needing assistance with instrumental activities of daily living (iADLs) and activities of daily living (ADLs), which capture limitations in independent living tasks and basic self-care, respectively. Participants were categorized as no impairment (no ADL or iADL limitations), iADL impairment (≥1 iADL limitation), or ADL impairment (≥1 ADL limitation). This categorization is consistent with established disability frameworks in which iADL limitations typically precede ADL limitations and ADL impairment that indicate more severe functional dependence (15, 16). Because MEPS provides summary indicators for ADL and iADL assistance rather than item-level measures, we also reported two representative component limitations available in MEPS – difficulty doing errands alone (iADL limitation) and difficulty dressing or bathing (ADL limitation) - in supplementary analyses to schedule clinically interpretable examples underlying these summary indicators.
Secondary Outcomes
Physical and Mental Health.
As secondary outcomes, physical and mental health status were assessed with two MEPS variables from the Veterans RAND 12-Item Health Survey (VR-12), which is administered as part of the MEPS Self-Administered Questionnaire. The VR-12 includes 12 items that capture health-related quality of life across eight domains and is summarized using two standardized composite scores: the Physical Component Survey (PCS) and the Mental Component Survey (MCS). PCS is derived from items assessing role limitations due to physical health, overall disease burden, bodily pain, and general health status, whereas MCS is derived from items assessing psychological well-being, emotional well-being, and social functioning. Responses to all VR-12 items are weighted and combined using established scoring algorithms to generate population-based PCS and MCS scores (mean 50, standard deviation 10 in the U.S. population). Using prespecified thresholds, we defined poor physical health as a PCS score <40 and poor mental health as an MCS score <40. Both PCS and MCS scores demonstrate high internal consistency and predictive validity in MEPS (17).
Analysis
After estimating the size and proportion of the at-risk population of Medicaid disenrollment, we compared all outcomes between adults who met work requirements and those who did not by using survey-design adjusted chi-square tests (18). We performed additional subgroup analyses by age group (ages 19–29, 30–49, and 50–64 years) as well as by sex to evaluate for heterogeneity of associations among beneficiaries. All analyses incorporated MEPS survey weights to generate nationally representative estimates (Data Supplement). Complete case analyses were performed due to low missingness (<2%). Analyses were performed using SAS, version 9.4 with significance defined as a two-sided p-value <0.05. This study did not require institutional board review approval because it used publicly available, de-identified data, as per institutional policy. We followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting guidelines.
Role of the Funding Source
The National Institutes of Health and the Patrick and Catherine Weldon Donaghue Research Foundation had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
Results
Population Characteristics
MEPS 2022–2023 data included 2,140 working-age adults with Medicaid coverage, representing a weighted population of 16,467,580 (mean age: 40.5 years, 54.4% female). An estimated 50.4% (8,294,916 ±SE 516,308) of adults in this population would not meet work requirements if implemented nationwide and, therefore, would be at risk of Medicaid disenrollment (Table 1). The mean age, gender distribution, racial identities, and geographic region were similar between adults at risk of disenrollment and those not at risk. In contrast, beneficiaries at risk of disenrollment were significantly more likely to have incomes below 200% of the federal poverty line, a high school education or less, and a higher prevalence of several chronic conditions. Among adults at risk of disenrollment, 33.5% (95% CI, 29.2%–37.9%) reported an illness or disability that limited their ability to work.
Table 1.
Baseline Characteristics of Medicaid Beneficiaries Aged 19–64 Years
| Medicaid Beneficiaries Aged 19 to 64 Years | At Risk of Medicaid Disenrollmenta | Not At Risk of Medicaid Disenrollmentb | |
|---|---|---|---|
| Annual weighted population ± SE (%) | 16,467,580 ± 818,910 (100) | 8,294,916 ± 516,308 (50.4) | 8,172,664 ± 487,732 (49.6) |
| Mean age (± SE), years | 40.5 ± 0.4 | 41.8 ± 0.6 | 39.1 ± 0.5 |
| Female (%) | 54.4 (51.4 – 57.3) | 57.5 (53.2 – 61.8) | 51.1 (47.0– 55.3) |
| Race/Ethnicity (%) | |||
| Hispanic | 25.0 (21.5 – 28.4) | 25.2 (20.8 – 29.6) | 24.7 (20.5 – 28.9) |
| White | 46.9 (42.8 – 51.0) | 48.7 (42.9 – 54.6) | 45.0 (40.0 – 50.1) |
| Black | 17.8 (14.8 – 20.8) | 15.4 (12.0 – 18.9) | 20.2 (16.6 – 23.8) |
| Asian | 7.1 (4.6 – 9.7) | 7.5 (4.4 – 10.5) | 6.8 (3.8 – 9.8) |
| Other or multiracial | 3.2 (2.3 – 4.1) | 3.2 (1.9 – 4.5) | 3.3 (1.8 – 4.7) |
| Income <200% FPL (%) | 50.0 (47.2 – 52.8) | 67.2 (63.8 – 70.5) | 32.7 (29.4 – 35.9) |
| High school degree or less (%) | 73.5 (70.5 – 76.4) | 78.4 (74.6 – 82.2) | 68.4 (64.1 – 72.8) |
| Region (%) | |||
| Northeast | 23.7 (19.1 – 28.3) | 24.2 (18.5 – 29.9) | 23.1 (17.4 – 28.9) |
| Midwest | 19.6 (16.0 – 23.3) | 18.5 (14.7 – 22.3) | 20.7 (16.0 – 25.4) |
| South | 23.4 (20.1 – 26.8) | 24.2 (20.3 – 28.2) | 22.6 (18.4 – 26.8) |
| West | 33.3 (28.6 – 38.0) | 33.0 (27.2 – 38.8) | 33.5 (28.0 – 39.0) |
| Chronic Conditions (%) | |||
| Hypertension | 27.1 (24.5 – 29.8) | 30.5 (26.5 – 34.5) | 23.7 (20.2 – 27.1) |
| Diabetes | 12.8 (11.0 – 14.6) | 13.8 (11.6 – 16.0) | 11.8 (9.0 – 14.5) |
| Asthma | 18.7 (16.4 – 21.1) | 20.2 (16.6 – 23.9) | 17.1 (14.2 – 20.1) |
| Myocardial infarction | 2.8 (2.0 – 3.6) | 4.5 (3.0 – 6.0) | 1.1 (0.4 – 1.8) |
| Coronary heart disease | 2.6 (1.8 – 3.3) | 3.4 (2.1 – 4.6) | 1.8 (0.8 – 2.7) |
| Stroke | 4.0 (2.7 – 5.3) | 6.4 (4.0 – 8.7) | 1.6 (0.5 – 2.7) |
| Cancer | 5.6 (4.2 – 6.9) | 5.0 (3.4 – 6.5) | 6.2 (4.1 – 8.2) |
| Emphysema | 1.4 (0.9 – 1.9) | 2.0 (1.2 – 2.7) | 0.9 (0.1 – 1.6) |
| Arthritis | 21.5 (18.8 – 24.2) | 25.2 (21.3 – 29.1) | 17.7 (14.6 – 20.9) |
Values are mean ± SE or % (95% CI). FPL = federal poverty level.
Self-reported as unemployed or working less than 20 hours/week, not receiving Social Security Insurance, not dually enrolled in Medicare, not unemployed due to being enrolled in school, with no dependents younger than age 14 in household during the survey period, and does not self-identify as Native American.
Self-reported as working at least 20 hours/week and not receiving Social Security Insurance, not dually enrolled in Medicare, not unemployed due to being enrolled in school, with no dependents younger than age 14 in household during the survey period, and does not self-identify as Native American
Functional Status
Across all three domains of physical, neuropsychological, and independent living function, adults at risk of disenrollment exhibited significantly higher levels of impairment than those meeting work requirements (Table 2).
Table 2.
Functional Impairment Among Adult Beneficiaries at Risk of Medicaid Disenrollment Under National Work Requirements
| At Risk of Medicaid Disenrollment Percentage (95% CI) |
Not at Risk of Medicaid Disenrollment Percentage (95% CI) |
P-value | |
|---|---|---|---|
| PHYSICAL LIMITATIONS | |||
| Limit in Physical Functioning | 19.1 (15.7 -- 22.5) | 9.0 (6.5 -- 11.4) | <.0001 |
| Difficulty Using Fingers to Grasp | 8.3 (5.8 -- 10.8) | 3.4 (1.8 -- 4.9) | 0.0008 |
| Difficulty Reaching Overhead | 12.1 (9.4 -- 14.8) | 4.6 (3.0 -- 6.3) | <.0001 |
| Difficulty Bending/Stooping | 16.8 (13.8 -- 19.8) | 7.1 (4.9 -- 9.2) | <.0001 |
| Difficulty Standing 20 Minutes | 14.5 (11.5 -- 17.5) | 5.5 (3.9 -- 7.1) | <.0001 |
| Difficulty Walking 3 Blocks | 15.6 (12.5 -- 18.7) | 6.5 (4.6 -- 8.5) | <.0001 |
| Difficulty Walking Up 10 Steps | 15.1 (12.1 -- 18.1) | 5.4 (3.7 -- 7.2) | <.0001 |
| Difficulty Lifting 10lb | 13.5 (10.7 -- 16.3) | 5.5 (3.5 -- 7.5) | <.0001 |
| NEUROPSYCHOLOGICAL IMPAIRMENT | |||
| Cognitive Deficit | 13.7 (10.9 -- 16.4) | 5.1 (3.0 -- 7.2) | <.0001 |
| Severe Psychological Distress | 12.0 (8.4 -- 15.6) | 7.1 (4.8 -- 9.4) | 0.0240 |
| Social Participation Limitation | 13.5 (10.4 -- 16.6) | 4.7 (2.7 -- 6.8) | <.0001 |
| FUNCTIONAL STATUS | |||
| Illness or Disability Limiting Ability to Work | 33.5 (29.2 -- 37.9) | 0.1 (0.0 -- 0.2) | <.0001 |
| Assistance with 1 or more iADL | 6.2 (4.5 -- 7.9) | 1.2 (0.0 -- 2.3) | 0.0003 |
| Assistance with 1 or more ADL | 3.5 (1.9 -- 5.0) | 0.2 (0.0 -- 0.6) | <.0001 |
| Difficulty Dressing or Bathing | 6.4 (4.0 -- 8.8) | 1.5 (0.6 -- 2.4) | <.0001 |
| Difficulty Doing Errands Alone | 11.5 (8.7 -- 14.3) | 1.4 (0.7 -- 2.1) | <.0001 |
| Use of Assistive Devices | 8.5 (6.0 -- 11.1) | 2.1 (0.9 -- 3.3) | <.0001 |
Values are % (95% CI). iADL= Independent Activity of Daily Living. ADL=Activity of Daily Living.
With respect to physical functioning, physical impairment was significantly higher among adults at risk of disenrollment compared to those not at risk (p<0.001) with severe physical impairment nearly three times more common among at-risk beneficiaries (12.4% [95% CI, 9.7%–15.1%] vs 4.5% [95% CI, 2.9%–6.0%]). Adults at risk of disenrollment were more than twice as likely to report limitations in each of the seven physical activity items in the composite measure (p<0.001) (Supplemental Table 2 and Supplemental Figure 1).
Neuropsychological impairment was also more common among adults at risk of disenrollment than those not at risk (p<0.001), including both mild impairment (15.4% [95% CI, 11.2%–19.6%] vs 9.4% [95% CI, 6.6%–12.1%]) and moderate to severe impairment (12.5% [95% CI, 9.1%–15.9%] vs 3.4% [95% CI, 1.6%–5.2%]). In particular, differences in cognitive impairment and social participation limitations between these groups were substantial (Supplemental Table 2).
Finally, limitations in independent living were also more prevalent among adults at risk of disenrollment than those who were not at risk, including needing assistance with one or more instrumental activities of daily living (6.2% [95% CI 4.5%–7.9%] vs 1.2% [95% CI 0–2.3%]) and one or more activities of daily living (3.5% [95% CI 1.9%–5.0%] vs 0.2% [95% CI 0%–0.6%]). With respect to the two specific measures tested, difficulty doing errands alone was much more common for at-risk beneficiaries versus those not at risk (11.5% [95% CI, 8.7%–14.3%] vs 1.4% [95% CI 0.7%–2.1%]), as was difficulty dressing or bathing (6.4% [95% CI, 4.0%–8.8%] vs 1.5% [95% CI, 0.6%–2.4%]) (Supplemental Table 2).
Physical and mental health
Of adults at risk of Medicaid disenrollment, 32.7% (95% CI, 27.8%–37.6%) reported poor physical health, 28.2% (95% CI, 23.2% - 33.3%) reported poor mental health, and 12.3% (95% CI, 9.2%–15.4%) had poor physical and poor mental health concurrently. These measures of poor health were significantly more common among adults at risk of disenrollment than those who would meet work requirements (Table 3; Supplemental Figure 2).
Subgroup analysis
In subgroup analyses, differences in functional impairment, poor physical health, and poor mental health were generally greater for men and older adults (Supplemental Tables 3–4).
Discussion
Although H.R.1 established work requirements for Medicaid expansion enrollees in 40 states (and D.C.), Congressional proposals to extend these mandates to all working-age Medicaid beneficiaries nationwide are gaining traction. We estimate that such an expansion would place approximately 8.3 million adults – approximately half of working-age Medicaid beneficiaries – at risk of disenrollment due to not meeting work requirements necessary to maintain Medicaid coverage.
One-third of adults at risk of disenrollment reported an illness or disability that limited their ability to work despite not receiving SSI benefits. Across all functional status measures, rates of impairment were substantially higher among beneficiaries at risk of disenrollment compared with those not at risk. These differences were more pronounced among men and older beneficiaries, particularly those aged 50 to 64 years, consistent with recent literature finding higher burden of chronic conditions in this age group (19). By examining a broad range of measures of day-to-day functioning, our study reveals that adults at risk of disenrollment are significantly more likely to experience difficulty with essential tasks necessary for independent living and self-care. Prior research has reported that such activity limitations are associated with a decreased likelihood of employment and lower labor force participation (20). Taken together, these findings indicate that many at-risk individuals appear to have substantial impairment that may meaningfully restrict their ability to work even in the absence of receiving formal disability benefits. In the context of ongoing debates around appropriate exemption criteria, this group represents a policy-relevant “gray zone” of adults between functionally healthy and disabled, with levels of frailty that may warrant clearer and more consistent policy consideration.
Prior state demonstrations have shown that work requirements result in substantial coverage loss without increasing employment.6 Even when pilot states have included exemption criteria for work requirements, many exempt adults have still been disenrolled due to the administrative complexity of reporting requirements (6, 21, 22). On a national scale, we found that adults at risk of Medicaid disenrollment exhibited higher levels of functional impairment, limiting their ability to perform basic tasks. Accordingly, even if some individuals would ultimately be exempt under state-specific policies, our findings suggest that a sizable number of these adults may struggle with navigating the reporting and verification requirements necessary to maintain coverage.
We also found that approximately 30% of adults at risk of disenrollment reported poor physical health or poor mental health, with 12% experiencing both. These findings underscore the potential consequences of Medicaid disenrollment among a group facing substantial physical and mental health needs. Prior studies have similarly reported poorer health status among adults who were unable to meet work requirements (23). In this context, a national expansion of work requirements could disproportionately result in coverage loss among individuals with greater health burdens and unmet health care needs.
Previous studies have focused on the effects of work requirements among Medicaid expansion enrollees under H.R. 1, including projections from the Congressional Budget Office that approximately 5.1 million adult expansion enrollees could lose Medicaid coverage due to work requirements under H.R. 1 (24). Chetty et al. used NHANES data to estimate that approximately 5 million adults would be at risk of disenrollment under H.R. 1 work requirements, although their analysis was not limited to Medicaid expansion states (19). Our study extends this work by evaluating the potential impact of work requirements if applied to all Medicaid enrollees nationwide, as under Congressional consideration. In that case, we found that over 8 million adults would be at risk of disenrollment if policies were adopted to expand work requirements nationwide instead of only to ACA expansion states.
Limitations
This study has several limitations. First, outcomes were self-reported and could be subject to recall bias. Second, we could not account for certain work hour requirement exemptions, including pregnancy and participation in substance use treatment programs, because MEPS did not capture these variables. Institutionalized adults were also excluded because MEPS only surveys civilian, non-institutionalized individuals. Although exemption criteria for work requirements typically specify full-time students, MEPS does not reliably differentiate between adults attending full-time or part-time school, so by excluding all adults who reported attending school as their reason for not working, we may have excluded part-time students who would not have been exempt. Third, our study period included the initial months after the pandemic-era continuous Medicaid enrollment provision ended in April 2023, which resulted in substantial loss of Medicaid coverage (25). Our estimates of the number of adults at risk of disenrollment under national work requirements may, therefore, represent an upper bound of the population that could be affected.
Conclusions
An estimated 8 million adults could be at risk of Medicaid disenrollment under policy proposals to extend work requirements nationwide. Adults at risk of disenrollment experienced significantly higher rates of functional impairment across physical, neuropsychological, and independent living domains than their counterparts who met work requirements. As policymakers consider expanding Medicaid work requirements nationally, these findings underscore the importance of revising exemption criteria to account for functional impairment and medical vulnerability.
Supplementary Material
Figure 2.
Poor Physical and Mental Health Among Adults at Risk of Medicaid Disenrollment
In MEPS, physical and mental health are assessed using the Veterans RAND 12-Item Health Survey (VR-12), which produces a physical component summary (PCS) and mental component summary (MCS) score. PCS is a composite score reflecting physical function, role limitations due to physical health and overall health status. MCS reflects social functioning, role limitations due to emotional health, and overall mental health. Both are composite summary scores standardized to national norms with a population mean of 50 and SD of 10, such that poor health is standardized as <40. In this study, poor physical health, poor mental health, and combined poor physical and mental health were statistically more prevalent among adults at risk of Medicaid disenrollment than those not at risk of disenrollment (p<0.05).
Funding:
This study was supported by the Patrick and Catherine Weldon Donaghue Medical Research Foundation (Wadhera) and National Heart, Lung, and Blood Institute T32HL116275 (Vyas),
Footnotes
Disclosures: Dr. Vyas reported support from the National Heart, Lung, and Blood Institute (T32HL116275) during the conduct of this study. Dr. Wadhera is the Principal Investigator of research grants from the National Heart, Lung, and Blood Institute (R01HL164561, R01HL174549) and the National Institute of Nursing Research (R01NR021686) at the National Institutes of Health, American Heart Association Established Investigator Award (24EIA1258487), and the Donaghue Foundation, and also receives research support from the Richard A. and Susan F. Smith Center for Outcomes Research, where he serves as Associate Director. He also serves as a consultant for Abbott Vascular and Chamber Cardio, outside the submitted work. All other authors have no other disclosures to report.
Reproducible Research Statement: The data used in this study are publicly available at https://meps.ahrq.gov/mepsweb/
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