Washington, D.C. — A new peer-reviewed study is raising serious alarms about who would actually lose Medicaid if Congress expands work requirements nationwide — and the answer isn’t who most politicians assume.
Published March 31 in the Annals of Internal Medicine, the study found that roughly 8.3 million adult Medicaid enrollees — about 50.4% of the 16.5 million adults ages 19 to 64 studied — would face disenrollment because they work too few hours. What makes the findings particularly troubling for long-term care advocates: those most at risk aren’t able-bodied individuals choosing not to work. They’re people with serious physical impairments, cognitive limitations, and daily-living dependencies that already make nursing home-level care a real possibility.
Who’s Actually at Risk
Researchers at the Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center analyzed enrollee data and found that the population most likely to lose coverage is also the most medically vulnerable. Many of the 8.3 million at-risk individuals have functional limitations — difficulty bathing, dressing, managing medications — that are typically associated with the kind of chronic conditions that lead people into skilled nursing facilities in the first place.
Current exemption frameworks under the One Big Beautiful Bill Act, which extended work requirements nationally, may not catch most of these individuals. The study argues that the administrative burden of proving an exemption alone could cost millions of people their coverage, even when they’d otherwise qualify to keep it.
The Nursing Home Connection
For skilled nursing facilities, the stakes are direct. Medicaid is the primary payer for more than 60% of nursing home residents nationwide. If even a fraction of those 8.3 million lose coverage before they need institutional care, many will arrive at facility doors uninsured — or not at all, getting sicker at home without support.
Industry advocates have already been sounding warnings about the cascading effects of Medicaid funding reductions on post-acute care access. This study adds a new dimension to that concern: it’s not just about cuts to reimbursement rates. It’s about beneficiaries losing coverage entirely before they ever reach a facility.
A Gap in the Exemptions
The research team noted that current exemption categories — which include caregivers, full-time students, and those with documented disabilities — rely heavily on self-reporting and paperwork compliance. For people with cognitive impairment or who lack access to legal help, navigating that process is a significant barrier. Many will simply fall off the rolls.
Critics of the policy have long argued that work requirements don’t increase employment — they increase uninsurance. This study adds peer-reviewed weight to that argument, showing that those most likely to lose coverage are also least equipped to fight for it.
The findings have drawn attention from patient advocacy groups and long-term care organizations, many of which are pushing Congress to revisit the exemption framework before implementation rolls out further.
Source: Annals of Internal Medicine, doi:10.7326/ANNALS-25-04811 (Published online March 31, 2026)
