On Monday, the Trump administration finalized a key rule that establishes national guidelines for the rollout of work requirements in Medicaid, and industry groups warn that the regulation could prove burdensome to enrollees and state programs.
The Alliance of Community Health Plans said in a statement that the final rule adds documentation requirements and tightens criteria for exemptions to the requirements, which will make it harder for individuals who need coverage to secure exemptions they may qualify for.
The organization also noted that most individuals enrolled in Medicaid are already working or in school.
"Work and community engagement are important goals, but [the] success of any Medicaid program should be measured by health outcomes," ACHP President and CEO Ceci Connolly said. "It would be a mistake to claim victory purely based on the number of Americans who lose coverage."
ACHP said in the statement that regulators should support states in offering more streamlined verification processes, which can back the workforce engagement effort while also maintaining program integrity.
The work requirements were established as part of last summer's massive H.R. 1 legislation, or the One Big Beautiful Bill Act. States must have a program in place beginning on Jan. 1, 2027, though some are rolling out their work requirements earlier.
Under the mandate, non-disabled adults must complete 80 hours of work, job training or schooling per month to stay enrolled in Medicaid. Monday's regulation further defines the Centers for Medicare & Medicaid Services' approach to exemptions for individuals who are medically frail, disabled or caregiving.
Jennifer Tolbert, deputy director of the program on Medicaid and the uninsured at KFF, said in a quick take post that "the rule adopts a restrictive definition of medical frailty that differs from states’ early expectations."
"Given the complexity of the provisions in the rule, states will likely face significant challenges in operationalizing the requirements in the next six months," Tolbert wrote. "With the short implementation timeline, states were already making implementation decisions that may not align with the rule."
"These challenges present risks for states given the potential for audits and financial penalties, but also for individuals who now face greater barriers to obtaining and maintaining coverage," Tolbert said.
Multiple provider groups echoed ACHP, expressing concern about the narrow definition adopted in the rule and the administrative work required to manage such a program. Jennifer DeCubellis, CEO of America's Essential Hospitals, said in a statement that the regulation "goes beyond what Congress intended."
"The new, unnecessary administrative burdens will increase the number of eligible Medicaid beneficiaries without coverage, creating further barriers to care while increasing uncompensated care costs for essential hospitals," said DeCubellis. "We look forward to working with CMS to identify less burdensome approaches to make sure that eligible Medicaid beneficiaries can access the lifesaving care that they need."
Jan Carney, M.D., president of the American College of Physicians, said the organization is "strongly opposed to the community engagement requirements, or work requirements, in the Medicaid program." As many people with Medicaid coverage are already employed or enrolled in education, the shift will not likely drive a significant increase in employment, she said.
"The Medicaid program is designed to ensure that those most vulnerable among us are able to access needed medical care," Carney said. "Instituting work requirements for the program could lead to millions of individuals losing health care coverage, putting at risk their health, financial security and lives."
The work requirements in conjunction with policies that slash special directed payments in Medicaid could erode the social safety net, the Primary Care Collective said in a statement.
CEO Ann Greiner said that the rule could impair practices and their stability at a time when both patients and providers are struggling with healthcare costs and access barriers.
"The PCC is disappointed by today’s interim final rule, which would further imperil access to high-quality primary care," Greiner said. "These top-down changes will force states to implement new requirements that will hamper access to preventive services and primary care."
Patient advocacy groups similarly slammed the rule. Families USA Executive Director Anthony Wright said in a statement that the rule "implements new bureaucratic barriers on millions of Americans, and many will fall off coverage as a result."
He said that the rule will require individuals who qualify for exemptions to provide duplicative documentation and eschews self-attestation.
"Far from protecting the vulnerable, this guidance significantly raises the barrier for demonstrating medical frailty, meaning many patients in the middle of treatment will have the new hassle of proving their condition, over and over, with any mistake or gap being penalized by the loss of their health care and coverage," Wright said.
Carl Schmid, executive director at the HIV+Hepatitis Policy Institute, dinged the rule for not exempting individuals with HIV from the work requirements and warned that people with the condition "cannot stay healthy without continuous access to lifesaving HIV treatment."
And Shaina Goodman, vice president of policy and government affairs at Community Catalyst, called the rule and the push for work requirements "haphazard and reckless." She said states should be afforded additional time to adapt to the rule to avoid unnecessary coverage losses.
"Millions will lose their coverage due to unnecessary and costly paperwork and administrative red tape," said Goodman. "Among those at particular risk are the very people Congress swore to protect—people with disabilities, chronic conditions and complex health needs like diabetes or cancer who should keep their health insurance but will fall through the cracks because of a self-inflicted and rushed timeline."