The Trump administration makes it harder for some sick Americans to maintain Medicaid
Millions of sick Americans may have a harder time maintaining or even enrolling in Medicaid coverage after the first federal work mandate begins in January in most states.
That’s because the Centers for Medicare and Medicaid Services this week issued a new rule that takes a harder line on defining which low-income adult enrollees qualify for the “medically frail” exemption. The rule guides situations regarding the implementation of the work instruction.
Under the rule announced Monday, to qualify for the exemption, enrollees must not only have a disease or medical condition, such as cancer or a behavioral health condition, but that condition must also significantly impair their ability to comply with the work mandate.
The comment came as a surprise to many states and patient advocacy groups and sparked an immediate backlash, with warnings that required health insurance would be removed from patient enrollees under the Medicaid expansion.
“This is going to put a much higher burden of maintaining insurance on people with very serious health problems for whom loss of coverage could be catastrophic,” said Jocelyn Guyer, senior managing director at Manatt Health, a law and consulting firm that advises states on Medicaid policy. “This will increase the number of people losing coverage.”
The labor mandate was included in the Big Beautiful Bill that President Donald Trump and his party passed last year. CMS is in the process of issuing rules to help states implement the law’s health provisions, including historic cuts to Medicaid. The agency said its primary focus on work requirements is to protect vulnerable people while increasing the self-sufficiency and economic mobility of Medicaid enrollees.
OBBBA requires Medicaid expansion enrollees ages 19 to 64 to work at least 80 hours per month, volunteer, attend school or participate in a work program, unless they qualify for certain exemptions. According to the Congressional Budget Office’s estimate last summer, approximately 5.3 million more people are expected to be uninsured in 2034 due to work obligations.
However, experts told CNN that tying the exemption to the enrollee’s inability to work is not included in the law itself.
Maintenance concerns
The rule sparked a swift backlash from multiple patient advocacy groups, who said a stricter interpretation would put people’s lives at risk by jeopardizing their insurance coverage and access to care.
“Because of these requirements, an individual fighting for his or her life in active cancer treatment will now have to climb, for some, insurmountable hurdles to obtain or maintain insurance,” said Jennifer Hoque, deputy policy director for the American Cancer Society Cancer Action Network. “If they don’t get through the system fast enough, they’ll go to chemotherapy or cancer surgery and realize they don’t have the insurance they need. Their life-saving treatments will be taken away from them.”
According to a group of 48 patient organizations, including the American Lung Association, the Crohn’s & Colitis Foundation and the National Alliance on Mental Illness, CMS’s interpretation is “clearly at odds” with the One Big Beautiful Bill.
“Redefining the law’s medical infirmity exemption to apply only to individuals who can prove they are unable to work and substantially limiting states’ ability to accept patients’ self-reports of compliance and exemptions starting in 2028 is clearly unlawful,” the group said in a statement.
“These policies will impose enormous paperwork burdens on patients and providers, disrupt months of planning by states, and create chaos just months before the January 2027 implementation deadline.”
CMS did not respond to a request for comment on advocates’ concerns.
Fight for states
The surprise comment adds an extra two-step hurdle for state Medicaid agencies, which already face tight deadlines to meet work requirement programs by January. Many are already setting up their systems based on unofficial guidance from CMS and now need to make changes. Meanwhile, Nebraska He started the work order last month but will now have to comply with the new rule.
What’s more, CMS does not provide guidance to states on how to define and evaluate whether a person meets medically impaired deductible criteria, said Jennifer Tolbert, deputy director of the Medicaid and Uninsured Program at KFF, a nonpartisan health policy organization. States will likely adopt different practices, meaning there won’t be a uniform standard for determining whether someone is too sick to work.
Further complicating the matter is that the severity of these enrollees’ medical conditions and the impact on their ability to work may change over time, as the rule states.
This ruling could also put doctors in a difficult position, as they could be asked to help determine whether someone can work, which could affect patients’ insurance coverage. This is generally not part of providers’ clinical practices and areas of expertise, Guyer said.
Additionally, starting in 2028, enrollees and Medicaid enrollees will only be allowed to self-certify once that they qualify for the medical frailty exemption. Going forward, if states don’t have data to confirm people’s eligibility, enrollees may be required to submit documentation, which could be a big boost for some.
States will also not be able to add additional categories to the exemption. For example, the rule states that being homeless does not automatically qualify a person as medically impaired because it is not a health condition. However, if this person has a substance use disorder or mental health problem, he/she will be able to benefit from this exemption.
Preventing fraud
CMS officials defended their interpretation of the law in a call with reporters that focused largely on the medical frailty provisions. They said states could use health claims data or request other documentation to determine whether an enrollee meets the criteria in the rule.
“The exemption ensures that job prospects are directed to those who can participate while protecting those who cannot,” said Dan Brillman, who manages CMS’s Medicaid program.
He oversees CMS and is a key player in the Trump administration’s fight against fraud in federal programs. Mehmet Öz linked the provisions with preserving program integrity.
“The mantra we kept repeating was that we were forgiving, but not stupid,” Oz told reporters, noting that the work order would protect Medicaid for vulnerable people. “We go after problem areas directionally, and we do it in a compassionate, forgiving way – but we don’t want to be stupid.”
The medically weak exemption is one of several examples of CMS’s stricter interpretations of the Big Beautiful Bill. Starting in 2028, the agency is eliminating the ability for enrollees to self-certify that they meet employment requirements or qualify for an exemption, such as serving as a caregiver, which could be important for gig workers or the self-employed.
In 2027, states will be able to agree to self-certify when reliable data is not available to prove work hours or exemption eligibility.
Öz warned that registered persons should be honest when giving their own declarations.
“In the rare cases where you validate yourself, you have to tell the truth,” he told reporters on Monday. “We will be talking to the different enforcement agencies to make sure the public knows this is not a joke.”
Separately, last month, CMS proposed a rule that would further restrict states’ ability to increase certain types of payments to providers beyond the limits Congress established in the law. These payments are used to encourage provider participation and improve access to care for Medicaid enrollees, but the agency argues the practice increases costs without leading to better health outcomes.
The stricter work mandate rule met with approval from at least one conservative health policy expert. Brian Blase, president of the Paragon Health Institute and an influential voice with the White House and Republican lawmakers, said it “strikes the appropriate balance” between preserving the integrity of Medicaid and accommodating those in need.
“Self-certification alone for eligibility or exemptions (especially for medical frailty) risks repeating the improper enrollment and fraud seen in other programs when verification standards are weakened,” he said in a statement.
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