Eliza Brader fears she will soon have to prove she is working to continue receiving Medicaid coverage. She thinks she shouldn’t have to do it.
Brader, 27, of Bloomington, Indiana, has a pacemaker and suffers from a painful joint condition. Additionally, he suffers from a spinal injury that has fused the vertebrae in his neck, making it impossible for him to turn his head.
The state Medicaid agency considers Brader “medically fragile,” giving him access to an expanded set of benefits, such as physical therapy.
But the new federal rules will require more than 18 million Medicaid beneficiaries nationwide to prove, starting in 2027, that they work, volunteer or study at least 80 hours per month to maintain their coverage.
Brader is exempt as long as she remains considered medically fragile.
But in the absence of clear guidelines at the federal level, states must reach agreement on how to define medical frailty, a high-impact decision that could cause many people to lose access to Medicaid, according to state officials, consumer advocates and health policy experts.
“I’m terrified,” Brader said. “I have already fought hard to get this medical care. »
Much at stake
President Donald Trump’s One Big Beautiful Bill Act will cut nearly $1 trillion in Medicaid funding over the next decade. Much of these projected savings would come from eliminating coverage for those who are not eligible under the new labor rules.
These cuts help fund other Republican Party priorities, such as increased border security and tax cuts that primarily benefit high-income earners.
Conservative lawmakers have argued that Medicaid — the government health insurance program for low-income or disabled people — has become too large, especially after it was expanded to more low-income adults under the Affordable Care Act (ACA). They also say that requiring recipients to work is a common-sense measure.
Trump’s new tax and budget law offers exemptions to many people who might have difficulty complying with work rules, including those considered “medically fragile.” The law defines certain conditions as medically fragile, such as blindness, disability, and substance abuse. But it doesn’t include many others.
Instead, the rule exempts those who have a “serious or complex health condition,” a term whose interpretation can vary by state.
State officials say they need more clarity to ensure people who can’t work for health reasons maintain their Medicaid eligibility. They also worry that, even with a clear definition, many people face the bureaucratic challenge of constantly having to prove that they are medically fragile, which is difficult if adequate medical care is not accessible.
“The stakes are high,” said Kinda Serafi, a partner at consulting firm Manatt Health.
The new work requirements will affect Medicaid beneficiaries in 42 states and Washington, DC. Eight states – Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas and Wyoming – have not expanded their Medicaid programs to include more low-income adults, so they will not have to implement these rules.
According to the nonpartisan Congressional Budget Office, these Medicaid work rules are expected to be the biggest factor driving the loss of health coverage over the next decade.
44% of adults covered by Medicaid programs in states that have expanded it have at least one chronic illness, according to KFF.
A challenge for States
State Medicaid agencies are rushing to implement the new rules with little guidance from the U.S. Department of Health and Human Services (HHS), which has yet to issue specific guidance. Agency spokesman Andrew Nixon said the federal definition of “medically fragile” would be clarified next year.
Ultimately, it will be up to states to decide who is sick enough to be exempt from work requirements. And it won’t be easy for state staff or IT systems to keep track of.
Each year, state eligibility systems evaluate millions of applicants to determine whether they qualify for Medicaid and other government programs. Now, these same systems will also need to check whether new or existing registrants meet work requirements.
Jessica Kahn, a partner at consulting firm McKinsey & Co., urged states to start planning now for how to adapt their employment status verification systems. States can do “a lot” even without waiting for federal guidance, Kahn — a former federal Medicaid official — said during a recent advisory hearing on the program. “Time is running out.”
State Medicaid officials are evaluating this challenge.
“Medical frailty is a very complex thing,” Emma Sandoe, Oregon’s Medicaid director, said during a recent panel. Conditions that prevent work, such as mental health disorders, are difficult to prove, he explained.
A state could try to use information in a person’s medical records, for example, to determine whether they are medically fragile. But this information may not clearly reflect a person’s health status, especially if they do not have regular access to medical services.
That’s a difficult task for eligibility systems that historically haven’t had to review medical records to evaluate applications, Manatt Health’s Serafi said.
“This is completely new for registration systems, and they are simply not prepared,” he added.
Lobbying groups representing private health insurance companies that administer Medicaid in several states have also called on federal officials to clearly define what it means to be medically fragile, so that the term is applied uniformly.
In a letter sent Nov. 3, Medicaid Health Plans of America (MHPA) and the Association of Community Affiliated Plans (ACAP) recommended that applicants be allowed to qualify for the waiver simply by indicating on their application that they have conditions that make them medically fragile. According to the two organizations, the successful implementation of these exemptions will be “crucial” given the “severity of the health risks of loss of coverage” for these populations.
Some state officials worry these work rules could have unintended consequences for people with chronic illnesses.
Jennifer Strohecker, who recently resigned as Utah’s Medicaid director, reiterated the seriousness of this problem, particularly for people with diabetes enrolled in Medicaid.
He explained that while they can live a functional life with insulin, that could change if they lose their coverage for not meeting the demands of their job.
Currently, whether someone is considered medically fragile depends largely on where they live.
For example, in Arkansas, people must indicate on their Medicaid application whether they have a disability, are blind, or need assistance with daily activities.
About 6 percent of the 221,000 people enrolled in the state’s Medicaid expansion program are considered medically fragile, according to Gavin Lesnick, a spokesman for the Arkansas Department of Human Services.
In West Virginia, the state accepts the medical fragility designation when a person self-reports it.
In North Dakota, the procedure is stricter. Applicants must complete a health questionnaire and submit additional documentation, such as medical history notes and treatment plans. More than half of applications were denied last year, according to Mindy Michaels, a spokeswoman for the Department of Health and Human Services.
The Indiana Family and Social Services Administration, which administers Medicaid in the state, declined to offer interviews and said it could not comment on individual cases, like Brader’s.
Brader fears the added bureaucracy could cause him to lose his Medicaid coverage again. She said that in 2019, she was temporarily kicked out of the program for failing to comply with state employment rules, when Indiana determined that her work as a student did not count as employment.
“Every time I’ve tried to get help from the state of Indiana, it’s been a bureaucratic nightmare,” he said.
While states wait for federal guidance, Kristi Putnam — a member of the conservative Cicero Institute and former secretary of the Arkansas Department of Human Services — said that even if a state creates a long list of conditions that qualify as medically frail, there will still be a line to draw.
“You can’t create one exemption policy that covers everything,” he said.
