Medicaid Work Requirements Under HR 1 Could Affect 5 Million Adults, Many With Chronic Illnesses
The sweeping “One Big Beautiful Bill Act” (HR 1), enacted in July 2025, introduces new federal work requirements for certain adults enrolled in Medicaid. While exempting individuals who are medically frail, pregnant, eligible for Medicare, or who have a disability or dependent child, the law mandates that other adult beneficiaries must work or volunteer at least 80 hours per month—or participate in an educational program—to maintain coverage. According to a recent analysis, roughly 5 million adults could lose Medicaid coverage by 2034 as a result of these provisions.
A cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) provides one of the first detailed looks at the clinical characteristics of adults most at risk of losing Medicaid under the new requirements. Researchers examined nonpregnant adults aged 20 to 64 years who receive Medicaid but not Medicare and who do not currently meet the 80-hour-per-month work threshold or qualify for an exemption.
The analysis, which included 344 participants representing approximately 5 million adult Medicaid beneficiaries nationwide, found that nearly 1 in 5 working-age Medicaid recipients (19.9%) could be subject to disenrollment under HR 1. The mean age of these individuals was 39 years, and two-thirds were women. Most were either searching for work (42.3%) or working fewer than 20 hours per week (22.8%).
Health burden among this group was high. Overall, 41.1% had 3 or more chronic conditions, and this rate climbed to 66.3% among adults aged 50 to 64 years. Nearly 1 in 5 in this older age group reported taking 5 or more prescription medications. The most prevalent conditions included dyslipidemia, obesity, hypertension, depression, and arthritis. This finding highlights the tension between the policy’s employment goals and the health realities of many beneficiaries who may face medical or functional barriers to steady work.
The authors also emphasized that while many of these adults could qualify for medical exemptions, state-level differences in defining and documenting “medical frailty” may make that process difficult. Such administrative barriers could lead to coverage losses even among those technically exempt from work requirements.
From a payer and policy perspective, the study suggests potential downstream implications for both coverage continuity and health outcomes. Disenrollment among individuals with multiple chronic conditions could interrupt access to essential medications and care, leading to higher acute-care utilization and costs later on. The Congressional Budget Office has projected that most of the 5 million expected disenrollments will stem from beneficiaries’ inability to meet or verify exemption criteria rather than from actual noncompliance with work requirements.
Although limited by reliance on self-reported data and the inability to assess disease severity, the analysis underscores the clinical vulnerability of those most likely to lose Medicaid under HR 1. If states struggle to effectively identify and document exemptions for medically frail adults, the resulting loss of coverage could have significant implications for chronic disease management, prevention efforts, and health equity across Medicaid populations.
Reference
Chetty AK, Ross JS, Chen AS. Clinical characteristics of adults at risk of Medicaid disenrollment due to HR 1 work requirements. JAMA. 2025; Oct 1:e2516533. doi: 10.1001/jama.2025.16533
