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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join host Jeff Byers, editors from Health Affairs Publishing, and guests as they discuss health policy’s most pressing news and trends.
Hello, and welcome to Health Affairs This Week. I'm your host, Byers. We are recording on 06/08/2026. Again, just another reminder, this month we have an insider event on antitrust with Lemore Daphne, Kathryn Gudixson, and Nathan Hostert as speakers. Please check that out.
Jeff Byers:Today on the podcast to discuss Medicaid work requirements, we have Alison Barkoff from the George Washington University. Alison, welcome to the program.
Alison Barkoff:Thanks so much for having me.
Jeff Byers:We're gonna talk about the new work requirements in Medicaid. Most listeners probably have a sense of what these work requirements are in theory, but, you know, maybe this is someone's first introduction to the topic. The one big beautiful bill act signed into law US work requirements for some Medicaid enrollees. So what Medicaid enrollees do these affect, etcetera?
Alison Barkoff:First, it's really important for listeners to understand that the one big beautiful bill act obey HR one is the largest reduction in federal funding for Medicaid in the program's history, about a trillion dollars, and about a third of that comes from these new Medicaid work reporting requirements and an estimate that about 5,000,000 people will lose their Medicaid coverage because of these new work requirements. It applies to all people who are in the Medicaid expansion population. That's about 20,000,000 people, about the third of people on Medicaid, that's 41 states who have expanded Medicaid, and another two states that have partially expanded. So virtually all states in this country are going to have to be navigating through these Medicaid work requirements. So pivoting to who are these people?
Alison Barkoff:If you look at the narrative that came out of congress that's coming out of this administration, it is quote unquote able-bodied people and a narrative that it is mostly young men sitting around playing video games instead of working in order to get health insurance through Medicaid.
Jeff Byers:They went they went after video games.
Alison Barkoff:They did go after video games, but that's not who it is. If you actually look at who this population is, and I work a lot on behalf of people with disabilities, chronic health conditions, older adults, about twenty percent of the Medicaid population are actually disabled. Think mental health conditions, people with significant disabilities that don't meet a social security disability standard. We have about six million older adults who are on Medicaid expansion and these work requirements go all the way to age 65. The reality about this is if you actually look at people who are on the Medicaid expansion, the vast majority, ninety two percent are either working, have disabilities or caregiving or in school.
Alison Barkoff:So this policy is targeted to a very small group of people. And when I did some research looking at who this eight percent of quote unquote able-bodied people are, they are not young, invincible men sitting around playing video games. In fact, they are about 80% women. They are primarily middle aged and older. 70% have a high school diploma or less, and they are disproportionately from rural areas.
Alison Barkoff:So that's who I'm worried about as we're talking about these work requirements.
Jeff Byers:Going back even further, thanks for that. Again, this could be someone's first introduction to the topic. So Medicaid expansion, you know, how did, you know, through the ACA, who did states expand Medicaid to if and when they did actually do the said expansion?
Alison Barkoff:Yeah. I mean, Medicaid expanded from, you know, specific individual populations to low income individuals up to a 138% of poverty. So that might have been just a low income person who did not, as I said, have a very significant disability that meets a Social Security standard, but it historically was a big group of people with chronic health conditions like mental health who might have HIV, who might have Parkinson's, who might be a low income older adult, and really reached this new group of people for whom Medicaid is critical in really addressing many of their health care needs, but who did not previously qualify through one of the very limited pathways and also for a very, very low income bar.
Jeff Byers:So you're looking at these middle aged, primarily women, rural, and did you say lower income as well?
Alison Barkoff:I did. Yeah.
Jeff Byers:Okay. And so can you explain the basics of these newer work requirements when looking at this potential population?
Alison Barkoff:So in the statute itself, they added a requirement that to get on Medicaid, to even be eligible and then to stay on Medicaid, you have to show that you are engaging in activities for eighty hours a month. It can be a combination of working, paid or unpaid, volunteering or going to school. So let me just say that again. To even get on Medicaid, you will have to show the month before or up to three months before that you have eighty hours of this mix of activities or that you meet some kind of exemption. And every single cycle, you will repeatedly have to show that you are constantly meeting these requirements to keep your health insurance.
Alison Barkoff:In the statute itself, I think what's really important is both the red tape and challenges for the many people who are gonna have to prove that they are engaging in these activities. Think of gig workers. Think of people who might have seasonal types of jobs. That's a challenge. But, again, I am really worried actually about the people who congress said in the statute should not have to repeatedly show they're working.
Alison Barkoff:They excluded, for example, pregnant and postpartum women, caregivers of children 13 or a caregiver of disabled people, veterans with a total disability rating, and what I want to spend most of our time talking about, they excluded an individual who is medically frail or has special medical needs. In the statute, they said that this medically frail includes five different groups. So people who are blind or disabled as defined by the Social Security Disability Standard, a very high bar of having to show that you cannot engage in any gainful employment. The second one is someone with a substance use disorder. The third, someone with a disabling mental disorder.
Alison Barkoff:The fourth is someone with a physical, intellectual, or developmental disability that impacts their ability to do things like eat or bathe or groom themselves, so an activity of daily living. And then finally, this catch all called a serious or complex medical condition to really capture the groups of people who need Medicaid to have treatment for their chronic health conditions. Think HIV. Think Parkinson's. Think cancer.
Alison Barkoff:That's what was intended here.
Jeff Byers:Okay. So that was the statute in OBA, and new guidance via an interim final rule was released June 1. So, what does that tell us? What did CMS say? What stood out to you?
Alison Barkoff:So what stood out to me, and, again, I worked with a lot of people in the communities that were intended by congress, if you look at the words of the statute, and frankly, what members of congress repeatedly told disability advocates that they and chronic health disease advocates and what they literally said in the markup. They said, don't worry. You're gonna be excluded. You're gonna be exempted. This is not going to impact you.
Alison Barkoff:And that is what over many months CMS has been informally working with states. And the presumption had been if you meet one of these conditions, which there is a push in the statute to do as much through data, so states have been putting together diagnosis codes that they might be able to find in people's medical records, that if you met and could show you had one of those conditions, you'd be exempted. A bomb dropped the day on June 1 that CMS put out this guidance and it was completely different than the expectations. What they said in the guidance is that to be considered in this medically frail exemption, not only do you have to show you have a condition that falls into one of those five categories, but you have to show that the condition substantially impairs your ability to engage in community activities like work, volunteering or going to school. That is an incredibly high bar.
Alison Barkoff:When you think about someone, for example, who might be getting cancer treatment, there might be some days they can work, some days they can't and losing their Medicaid will certainly mean that they can't access the treatment that they need to work and engage in community activities. Think of the burden on states who had planned to just, as much as possible, use data to identify conditions, somehow now people are going to have to show that their condition is substantial enough to impact work and that is not the kind of thing we would typically be finding in medical records. It is causing quite a concern with not just advocates for people with disabilities and chronic health conditions, but states are completely flipping out because they have spent the last six months planning around, based on informal guidance from CMS and conversations, an entire system that now will have to be upended.
Jeff Byers:Yeah. There's been some good reporting in Politico that I can find the particular article I'm thinking of in the show notes of I think it's like states bulk at Medicaid work requirements, and it it does a really nice job of, like, showing how there could be administrative burdens for for certain states based on the processes they were not aware that they were going to. But it's not my reporting, so I will I will share that link in the show notes when when I find it. But so when we look at and do we talk about how that people can self identify in 2027 and then has more paperwork in 2028? Do we talk about that, about, like, every six months or something along those lines?
Alison Barkoff:Yeah. So going back to comparing the statute to what CMS did, as we have seen in the handful of states that have had work reporting requirements in place that's primarily Arkansas and Georgia, huge amount of red tape means that people who should be eligible, who do meet the requirements actually end up losing Medicaid because of the procedural hurdles, because of the red tape. And that's why in the statute itself, it says whenever possible, a state should use data before they even go to a person to ask for additional information. Now again, what came out in informal guidance from CMS was first of all that you can mostly use the codes which again would mean you won't have to go to people in most circumstances and the second thing was that people could attest to their own circumstances. Think about some of the exemptions like a caregiver of a person with a disability.
Alison Barkoff:What kind of information are you going to be able to give to document that you are a caregiver? It is probably gonna have to be a representation. When we start getting to can you work or not, how do you feel after cancer treatments, again, that makes sense that it would probably be, something that you would attest to. These, regulations from CMS very much narrow in when you can use self attestation particularly around medical frailties. So they recognize the first year, there's probably gonna have to be some flexibility but it says starting in the second year, so beginning January 2028, in order to prove medical frailty, someone can only self attest one time and after that, they will have to put in documentation.
Alison Barkoff:So again, this is burden upon burden upon burden, more on the state, bigger barriers and red tape for Medicaid beneficiaries who have health conditions that need health care to actually be able to stay healthy, work, and honestly be able to survive.
Jeff Byers:Yeah. So we've been kinda dancing around it, but so what impacts? We've talked about some impacts of work requirements under these new guidance that may have on vulnerable populations. I know you've been in this space for a long time. You know, what has the research been shown on this in the past on work requirements, and and what do you expect might be impacted in these new guidance?
Alison Barkoff:I am incredibly concerned that CMS's guidance is incredibly harsh and will have pretty drastic impacts on vulnerable populations. You know, when we look at Arkansas and Georgia and other places that have put in place these work requirements, we know it is actually some of these populations that have challenges that have the hardest time making their way through this red tape and as I described, this is much more red tape than what existed in Arkansas and Georgia where we saw in Arkansas tens of thousands of people falling off of Medicaid because of these procedural, issues. And in Georgia, tens of thousands of people who should have been eligible and weren't able to come on. I think we heard again and again from congress, don't worry, these vulnerable populations who need Medicaid won't have to jump through these hoops and yet we see big hoops and an incredibly high standard to be able to get an exemption. I don't know how someone will be able to prove that their condition substantially impacts their ability to work or volunteer.
Alison Barkoff:I guess they'll have to go to a doctor or some kind of provider and if you don't have insurance, and again, you cannot even get on Medicaid until you prove that you either are meeting the community engagement requirements or you are exempt, how are you going to do that? I'll just also mention that one place where the rule is less harsh is around exceptions for caregivers of people with disabilities. Pretty broad definition both for caregiver and disability. That's really good for caregivers but the irony here is the caregiver will likely be exempted but because of this incredibly high standard for medical frailty, the person receiving care, the disabled person, will be very unlikely to be able to be exempted and I think that to me shows how harsh this is and the incredibly hard impact that it is going to have on people with chronic health conditions, older adults, this goes all the way up until someone turns 65. Think about that.
Alison Barkoff:And the many, many people with a range of disabilities.
Jeff Byers:So Alison Barkoff, as we wrap up, what are the streets saying about this interim final rule, which, has common period through July 31?
Alison Barkoff:I would use one word to describe the last week, and I would say chaos and confusion. You know, from the state side, we have states who have been spending months and months and months investing in data systems, starting to develop notices to people that were based on one set of understanding and the rule from CMS completely changed that. I mean, of a state like Nebraska who decided to roll out its rule early, you know, I would assume in consultation with CMS and what they have started doing does not comply with this rule. So on the state side, lots of questions, lots of concerns and a feeling that they are barreling towards a 01/01/2027 start date that they will not be ready for. I would say an incredible concern and fear on behalf of organizations that represent people with chronic health conditions, older adults, people with disabilities.
Alison Barkoff:Again, they were explicitly told by members of congress, this will not apply to you. You'll be exempted. Don't be worried. And then literally this rule comes out that is going to mean many many people who had been and must be exempted are left hanging in limbo. So I would say more unanswered questions than than answers right now, and I think we may be seeing more to come whether it's more guidance from CMS, states going to CMS and saying we need more time, governors going to members of congress and the administration saying slow this down, change the rules, or frankly, we might even see litigation about this regulation.
Alison Barkoff:So much more to come, but this is not the end of the story. I feel like it's just the beginning. I'll just mention that some colleagues and I have worked on kind of an initial analysis of the medical frailty provisions in the CMS rule and what it means, what we're hearing from the advocacy community, what we're hearing from providers, and hopefully that will be out in Health Affairs Forefront in the next week or so.
Jeff Byers:Well, Barkoff, thanks again for joining us today on Health Affairs This Week. If that article has gone live by the time this is published on Friday, we will put a link to the show notes. If not, our listeners should bookmark Health Affairs Forefront to never miss an article. It's a great resource for timely topics in the health policy space. Alison Barkoff, thanks again for joining us on Health Affairs This Week.
Alison Barkoff:Thanks again for having me.
Jeff Byers:Yeah. And if you, the listener, enjoyed this episode, send it to the gamer in your life. Thanks, and we'll see you soon.