By 2028, there could be between 4.9 million and 10.1 million fewer people enrolled through Medicaid expansion in an average month as a result of Medicaid work requirements and six-month redeterminations, according to a March 25 research report from the Urban Institute and funded by the Robert Wood Johnson Foundation.
The wide numerical range stems from possible ways expansion states, as outlined in the One Big Beautiful Bill Act, could approach implementation. The Urban Institute employed its health insurance policy simulation model to generate projections.
Here are six things to know from the report:
- Those ages 50 to 64 years old could be particularly vulnerable to losing Medicaid under work requirements and more frequent redeterminations. This is because people in this age range are less likely to live with dependent children no older than age 13 and automatically satisfy the work requirement through employment. Enrollment losses could range from 30% to 65%.
- Other groups of people may experience steeper enrollment losses, as well, due to challenges with confirming work activity, such as self-employed people. Between 19% and 37% of working people could still lose Medicaid coverage, even if they are meeting the requirement but struggle to document their progress.
- Adults who are medically frail or have special medical needs could qualify for an exemption, but may not receive it, resulting in further improper coverage losses. Caregivers may also face challenges with gaining an exemption.
- The Urban Institute predicts Medicaid expansion churn will rise, threatening coverage stability. This could elevate administrative costs to sustain enrollment.
- The report cites three independent studies to demonstrate Arkansas work requirements as a case study. The Arkansas program was linked to an increase in uninsured adults, as well as no increase in employment.
- While CMS has shared some early guidance, the agency has until June 2026 to flesh out state flexibilities.
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