Washington, D.C.<\/strong> — A major new analysis is sounding the alarm: as many as 10 million Americans could lose Medicaid coverage within two years, and the fallout for nursing homes could be severe.<\/p>
Researchers at the Urban Institute, with support from the Robert Wood Johnson Foundation, published findings this week estimating that between 4.9 million and 10.1 million people would lose Medicaid access by 2028 under work requirements included in H.R. 1 — the so-called “One Big Beautiful Bill” passed by the House last year. The range depends heavily on how aggressively states choose to implement the new rules.<\/p>
For skilled nursing facilities, which rely on Medicaid to cover roughly six in ten of their residents, the numbers are hard to ignore.<\/p>
Who’s Most at Risk<\/strong><\/p>
The study’s findings complicate the political framing around work requirements. More than 91% of adults currently enrolled in Medicaid expansion are already working, in school, caregiving for a family member, actively looking for work, or dealing with a health condition that limits their employment — meaning the requirement would largely hit people who already have legitimate reasons for their situation.<\/p>
Among those at greatest risk of losing coverage are older adults, family caregivers, the self-employed, and people with physical or mental health conditions. The researchers estimate that between 19% and 37% of working enrollees could lose their Medicaid coverage simply because of the complexity of proving compliance.<\/p>
That’s not a safety net failure — it’s a paperwork failure. And the nursing home sector has seen this pattern before.<\/p>
Experience from Arkansas, the only state to run a full-scale Medicaid work requirement program before courts struck it down, showed that the vast majority of people who lost coverage were actually exempt or already working the required hours. They just couldn’t navigate the bureaucratic process to prove it.<\/p>
The Nursing Home Connection<\/strong><\/p>
Family caregivers are specifically flagged as a high-risk group in the Urban Institute report — people who stay home to care for disabled household members or elderly parents. These are the same families that nursing homes depend on as partners in care, and often as the decision-makers who choose whether a loved one enters a facility at all.<\/p>
When those caregivers lose Medicaid, they often lose access to the health services that keep them able to provide care in the first place. That’s not just a personal crisis — it’s a system stress point that ripples through the entire long-term care continuum. Family caregivers already provide more than $1 trillion in unpaid work annually<\/a>, and stripping their health coverage won’t reduce that burden — it’ll shift it.<\/p>
The broader risk is equally direct. Medicaid is the financial backbone of skilled nursing care in America. New enrollment losses — even among people who are ultimately exempted — create gaps in coverage that take months to sort out. During that time, residents may face billing limbo, families may delay nursing home placement, and providers may absorb costs they can’t recoup.<\/p>
Best Case Is Still Bad<\/strong><\/p>
“Even in a best-case scenario, work requirements will cause millions of people to lose their Medicaid coverage,” said Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation. “And if states do not implement the law with care, that number could double.”<\/p>
The Urban Institute modeled three implementation scenarios — high, medium, and low mitigation — based on how much administrative work states take on versus placing the burden on individual enrollees. In the most optimistic scenario, with robust data-matching to ease compliance, losses still reach nearly 5 million. In the worst case, they hit 10 million.<\/p>
No state has yet announced a high-mitigation approach. Most are still working through implementation plans.<\/p>
For nursing home operators watching state Medicaid budgets with one eye and federal policy with the other, this report adds another dimension to an already precarious picture. The question isn’t just what Medicaid pays — it’s how many people will still have it.<\/p>
