- Between 5 million and 10 million people could lose Medicaid coverage in 2028 due to work requirements and six-month eligibility redeterminations mandated under the One Big Beautiful Bill signed by President Trump in July
- 2 to 3.1 million enrollees could lose coverage from the shift to semi-annual eligibility checks alone; an additional 3 to 7 million could be cut due to the new 80-hour monthly work requirement
- 19% to 37% of those who already work and legally qualify could still be disenrolled due to paperwork and documentation challenges — not because they are ineligible
- Even in the best-case high-mitigation scenario, Medicaid expansion enrollment drops from 18.4 million to 13.5 million — a loss of nearly 5 million covered lives
What Happened?
A new analysis by the Urban Institute and Robert Wood Johnson Foundation projects that between 5 million and 10 million people could lose Medicaid coverage in 2028 due to sweeping policy changes in the One Big Beautiful Bill, signed into law by President Trump last July. The law requires many adults who enrolled through the ACA Medicaid expansion to document 80 hours per month of work, education, or volunteer activity to maintain coverage. It also mandates eligibility redeterminations every six months instead of annually. Researchers modeled three scenarios — low, medium, and high state-level mitigation — based on how aggressively states work to protect enrollees through automatic data-matching, broader exemption definitions, and accessible documentation processes. Even under the most protective scenario, expansion enrollment falls from 18.4 million to 13.5 million — a decline of nearly 5 million people. Under the low-mitigation scenario, that figure surpasses 8 million.
Why It Matters?
This represents the largest structural change to Medicaid in decades, affecting a program that covers 76 million Americans. The financial exposure for the healthcare sector is significant: hospitals, managed care organizations, and state Medicaid budgets are all heavily dependent on continuous enrollment. The analysis reveals a particularly troubling dynamic — people who already work and qualify for the program could still lose coverage due to documentation burdens. Between 30% and 73% of self-employed enrollees subject to the work mandate could be disenrolled because automatic income verification for the self-employed is technically difficult. Caregivers of family members with disabilities face disenrollment rates of 19% to 52%, even though they are supposed to be exempt. For healthcare investors and operators, this translates directly into higher uncompensated care costs, increased bad debt, and potential pressure on Medicaid managed care plan margins.
What’s Next?
Implementation affects enrollees starting in 2028, giving states roughly two years to build the infrastructure needed to minimize unnecessary coverage losses. States that invest in automatic data-matching and broad exemption definitions will blunt the impact significantly — but political and resource constraints will vary widely. Managed care organizations with large Medicaid books of business should be closely monitoring state-level implementation plans; the difference between high and low mitigation scenarios represents millions of covered lives and billions in premium revenue. Hospital systems should be stress-testing their uncompensated care assumptions now. Congressional debate over further Medicaid cuts — including proposals to cap federal matching funds — is expected to continue through the 2026 budget cycle, adding additional uncertainty to an already volatile policy environment.
Source: Healthcare Dive
