On Monday, June 1, 2026, the Centers for Medicare & Medicaid Services issued an interim final rule implementing new Medicaid work requirements. The requirement was enacted as part of H.R. 1, the “One Big Beautiful Bill.” The idea may sound simple: certain adults on Medicaid will have to prove they are working, volunteering, going to school, participating in approved training, or doing another qualifying activity for at least 80 hours per month. In reality, this policy could become a paperwork trap for millions of people who depend on Medicaid.

Why This Matters

Medicaid serves many different people. It supports children with serious health needs, people with disabilities, older adults, people with mental illness, family caregivers, people recovering from substance use disorders, low-wage workers, rural residents, and people with intellectual disabilities and autism. Many people on Medicaid already work full-time or part-time. Others are caring for children, aging parents, spouses, siblings, or loved ones with disabilities. Many are managing serious health conditions or trying to stay stable enough to live safely in their communities. Their lives do not fit neatly into a federal form, a state computer system, or an algorithm-driven eligibility process.

The Paperwork Risk

H.R. 1 includes exemptions for people who are disabled or medically frail. Those exemptions are essential. But exemptions only work if people understand the rules, get the right paperwork, submit it on time, and are recognized correctly by state systems. That is where the danger begins. Government bureaucratic errors occur frequently, especially in states with outdated or poor data-tracking systems. People can and often do lose Medicaid because a government notice was buried or lost in the mail, a form was late, a computer system went down, or a disability or illness was not documented in exactly the right way.

Some states have not updated key eligibility and data systems for many years. Yet people on Medicaid are expected to navigate those systems as if everyone has a lawyer, a social worker, reliable internet, a working printer, transportation, and extra hours in the day to fight with a government office. That is not how real-life works, especially for those who are just trying to get by.

Who Could Be Harmed

The Administration claims these rules are intended to prevent fraud and strengthen Medicaid. But many of the people placed at risk are not gaming the system. They are already working, caregiving, recovering, managing illness, or living with disabilities. When people lose Medicaid, they can lose access to daily medicine, treatment, home care, personal assistance, recovery services, behavioral health care, or the community supports that keep them alive and out of crisis. Sometimes, people do not survive those mistakes. Once Medicaid is lost because of error or bureaucratic confusion, it can take months or even years to restore eligibility. During that time, people may lose health, housing stability, employment, independence, direct support and connection to their communities.

Urban Institute State-by-State Estimates

The Urban Institute estimates that 4.6 million to 5.2 million Medicaid expansion adults ages 19 to 55 could lose federally funded Medicaid under a federal work requirement scenario. The table below shows the Urban Institute’s projected coverage loss ranges for Medicaid expansion adults ages 19 to 55 in the 40 expansion states and the District of Columbia included in its analysis. For non-expansion states, the table notes that Urban did not estimate coverage losses under this specific Medicaid expansion work requirement model. These figures should not be read as a full measure of all Medicaid harm, but they do show the scale of people who could be pushed into the paperwork trap in states where the Urban Institute modeled coverage losses.

State/Jurisdiction	Estimated adults who could lose coverage
Alabama	Not estimated by Urban Institute (non-expansion state)
Alaska	10,000–11,000
Arizona	166,000–189,000
Arkansas	62,000–70,000
California	1.0–1.2 million
Colorado	95,000–108,000
Connecticut	74,000–85,000
Delaware	17,000–20,000
District of Columbia	26,000–30,000
Florida	Not estimated by Urban Institute (non-expansion state)
Georgia	Not estimated by Urban Institute (non-expansion state)
Hawaii	24,000–27,000
Idaho	17,000–20,000
Illinois	193,000–220,000
Indiana	102,000–116,000
Iowa	34,000–39,000
Kansas	Not estimated by Urban Institute (non-expansion state)
Kentucky	120,000–136,000
Louisiana	116,000–132,000
Maine	11,000–13,000
Maryland	95,000–109,000
Massachusetts	86,000–98,000
Michigan	145,000–165,000
Minnesota	67,000–76,000
Mississippi	Not estimated by Urban Institute (non-expansion state)
Missouri	69,000–78,000
Montana	23,000–27,000
Nebraska	13,000–15,000
Nevada	59,000–67,000
New Hampshire	17,000–19,000
New Jersey	115,000–131,000
New Mexico	75,000–86,000
New York	743,000–846,000
North Carolina	171,000–195,000
North Dakota	5,000–6,000
Ohio	158,000–180,000
Oklahoma	47,000–53,000
Oregon	83,000–95,000
Pennsylvania	174,000–198,000
Rhode Island	25,000–29,000
South Carolina	Not estimated by Urban Institute (non-expansion state)
South Dakota	8,000–9,000
Tennessee	Not estimated by Urban Institute (non-expansion state)
Texas	Not estimated by Urban Institute (non-expansion state)
Utah	20,000–23,000
Vermont	7,000–8,000
Virginia	98,000–111,000
Washington	121,000–138,000
West Virginia	38,000–44,000
Wisconsin	Not estimated by Urban Institute (non-expansion state)
Wyoming	Not estimated by Urban Institute (non-expansion state)

 

NADSP’s Concerns

The National Alliance for Direct Support Professionals is especially concerned about the impact on people with intellectual disabilities and autism, families, and the broader community of people who rely on Medicaid-funded services and supports. Medicaid is the foundation of community living. It helps people remain in their homes, avoid unnecessary institutionalization, receive needed care, and participate in family and community life. Work requirements should not discourage people with disabilities from working when they can. They should not punish people whose work hours fluctuate. They should not harm family caregivers. And they should not make health care depend on whether someone can survive a confusing paperwork process.

NADSP Recommendations

NADSP urges CMS and state Medicaid agencies to implement these rules with caution, fairness, and humanity.

Federal and state officials should:

1. Preserve broad exemptions for people with disabilities, serious health conditions, family caregiving responsibilities, and medically frail conditions.
2. Allow simple and accessible ways for people to prove exemptions.
3. Permit self-attestation when reliable records are unavailable.
4. Use existing state and federal data before requiring people to submit new paperwork.
5. Ensure notices are clear, accessible, and available in plain language.
6. Prevent eligible people from losing Medicaid because of paperwork mistakes, data delays, computer errors, or inaccessible reporting systems.
7. Track and publicly report how many people lose coverage, why they lose coverage, and whether they were likely eligible for an exemption.

If our nation still believes in a safety net for people in need, more must be done to preserve programs desperately needed by millions. Work should not become a trap. Health care should not depend on whether someone can survive a broken paperwork system. Medicaid should not be weakened in the name of reform when the result is that sick people, disabled people, working poor people, caregivers, and families are left frightened, confused, and abandoned.