Seasonal work risks Medicaid work requirement compliance

Nearly a fifth of the people at risk of losing coverage due to Medicaid work requirements aren't people who choose not to work, according to data in JAMA Health Forum. Instead, they're people who just miss the 20-hour requirement laid out by CMS, or else have variable work hours due to seasonal roles.

Medicaid work requirements have been a source of consternation for health advocates since they were first approved as part of President Trump's One Big Beautiful Bill Act. Starting January 2027, those in Medicaid expansion states will be beholden to 20-hour community engagement requirements, which include activities like going to work, caregiving, schooling or volunteering. There are some exceptions, such as for people with disabilities or "medical frailty."

Work requirements, plus more frequent eligibility checks, are expected to cut coverage for 5 to 10 million people, according to estimates from the Urban Institute and Robert Wood Johnson. The groups note that between 19% and 37% are likely to lose coverage, specifically due to the rule's work documentation requirements, not because they don't work.

But the JAMA Health Forum researchers said the impacts could run deeper than the red tape.

"Although many expect the administrative burdens associated with work-reporting requirements to be the primary source of disenrollment, the impact of insufficient and/or variable work hours on potential disenrollment among low-income adults is unknown," they wrote.

The researchers looked at data from the 2023-2025 Current Population Survey to describe the employment of 19,476 adults aged 18-64 who were likely Medicaid expansion enrollees. Using that data, the team assessed the risk of noncompliance with new Medicaid work requirements.

Overall, 19.8% of the study population are at risk of noncompliance, not because they don't work, but because their work hours fall short of the requirements spelled out by CMS. Of those people, 13.6% would lose Medicaid coverage, as their hours total "near" the required threshold. The team defined "near" as plus or minus 5 hours.

The remaining 7.6% of people would be impacted because their hours are variable, most often due to seasonal employment. For example, an individual might meet the work requirement threshold eight months out of the year, but if their work stops during the summer, they will fall short and lose coverage.

Women had a 22% higher risk of noncompliance, the researchers said. Non-Hispanic White people and those with lower educational attainment were also at higher risk of noncompliance. Meanwhile, those who were married had an 18% lower probability of noncompliance.

CMS pitched Medicaid work requirements as a way to put low-income adults on the path to better employment while also helping cut government spending.

"This rule helps Americans build skills and independence through work, education, job training, or community service, creating new opportunities for themselves and their families," CMS Administrator Mehmet Oz said when announcing the work requirement guidelines earlier this summer.

But critics of the rules say Medicaid work requirements will kick people already working off the program. This latest data gives deeper insight into the rule's impacts.

Sara Heath is an executive editor at Xtelligent Healthcare Media, where she covers patient engagement, healthcare policy and health IT.