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Fact check: How do Medicaid work requirements affect people with chronic illnesses?
Executive Summary
Medicaid work requirements, as proposed and analyzed in recent studies, threaten to disenroll millions of adults—many of whom have multiple chronic conditions—and are linked to decreased coverage, no increase in employment, and projected excess mortality. The evidence shows administrative burdens and imperfect exemptions concentrate harms on people with chronic illnesses, disabilities, women, and unhoused populations [1] [2] [3].
1. Claims on the scale: How many people are at risk and what researchers say about chronic illness
Recent analyses claim that millions of Medicaid adults would be affected if federal work requirements are enacted. A study estimated roughly 5 million adults could be subject to new requirements, with about 41.1% of those at risk carrying three or more chronic conditions [1]. Broader estimates place as many as 36 million adult enrollees at risk under some proposals, indicating variation in scope depending on the policy design and population counted [4]. The findings cohere around a central claim: a substantial share of the population flagged by work rules has significant chronic disease burdens, which raises direct concerns about continuity of care and the ability to meet work-related activities.
2. Claims on health outcomes: Evidence linking work requirements to morbidity and mortality
Multiple recent studies model or measure health outcomes tied to work requirements and loss of coverage. A JAMA analysis found that those most likely to lose coverage have high chronic disease prevalence, with 41% having three or more conditions [2]. A Lancet modeling study projects between 7,049 and 9,252 excess deaths annually attributable to work-requirement-driven coverage losses and worsening control of diabetes, hypertension, and hyperlipidemia [3]. Observational analyses report decreased insurance coverage and worsened access to care without employment gains, and trends toward worse cardiovascular health among affected adults [5]. These pieces together support the claim that coverage losses from work rules translate into measurable declines in health and increased mortality risk.
3. Claims on employment effects: Do work requirements actually increase employment?
Several analyses claim work requirements do not reliably increase employment among Medicaid enrollees. National and state-level studies found no meaningful rise in employment following implementation of work conditions, while administrative hurdles led to coverage churn instead [5]. A May 2025 study found nearly two-thirds of working-age Medicaid adults were already working, and additional reporting burdens disproportionately risked coverage loss rather than promoting job entry [6]. Modeling and program evaluations therefore converge on the claim that work requirements produce administrative disenrollment without corresponding employment benefits, undermining a primary policy rationale.
4. Claims on administrative burden and the inadequacy of exemptions
Analysts assert that reporting requirements and exemption systems fail to protect people with chronic illness and disabilities. The National Health Law Program documented that exemptions for people with disabilities often do not function effectively, creating disincentives to work and imposing extra administrative risk [7]. The Center for Health Care Strategies emphasized that federal-level requirements represent a major policy shift and that states need deliberate design to mitigate unintended disenrollment, particularly for chronically ill enrollees [8]. Empirical work links administrative complexity to higher rates of procedural loss of coverage, supporting the claim that bureaucratic hurdles, not inability to work, drive many coverage losses.
5. Competing viewpoints and policy design — where the debate centers
Proponents of work requirements frame them as incentives to increase employment and reduce program costs; critics argue evidence shows no employment gains and substantial health harms. The literature reveals a split between policy intent and empirical outcomes: while some policymakers emphasize potential labor-market activation, peer-reviewed evaluations and modeling studies document coverage reductions, health deterioration, and excess deaths [3] [5]. Policy design features—such as definition of compliant activities, reporting cadence, and real-time exemptions—determine outcomes, meaning the stakes hinge on detailed administrative rules rather than the abstract idea of “work requirements” alone [8].
6. Missing pieces and practical implications for people with chronic illnesses
What remains under-explored are long-term follow-ups on health trajectories after reenrollment, granular state-by-state analyses of exemption efficacy, and real-world evaluations of streamlined reporting systems. Existing work underscores that people with chronic illnesses are particularly vulnerable to coverage disruption, with downstream effects on disease control and mortality [1] [2] [3]. Policymakers considering work mandates must weigh the documented administrative and health harms, invest in robust protections and outreach if pursuing such policies, and prioritize longitudinal monitoring to detect unintended consequences early [6] [8].