A new study suggests that nearly one in five Medicaid-eligible adults in expansion states could be at risk of losing health coverage because they may not consistently meet new federal work requirements. Women, unmarried adults, White individuals, and people with lower levels of education were among those more likely to have insufficient or inconsistent work hours.

The requirements, established under the One Big Beautiful Bill Act (OBBBA), are scheduled to take effect nationwide on January 1, 2027. Adults covered through the Affordable Care Act’s Medicaid expansion will generally need to demonstrate at least 80 hours per month of work, volunteering, education, or job training, although certain groups will be exempt. The broader legislation is expected to reduce federal Medicaid spending over the next decade substantially.

Published in JAMA Health Forum, the study found that 19.8 percent of Medicaid-eligible adults in expansion states were at risk of failing to meet the requirements. About 13.6 percent were close to the minimum work-hour threshold, while 7.6 percent reported highly inconsistent work hours. Researchers warned that these patterns could put millions of people at risk of losing coverage once the requirements are implemented.

The findings also challenge the perception that Medicaid recipients who would be subject to the requirements are largely unemployed. More than 66 percent of applicable recipients were participating in the labour force, and among those workers, more than 85 percent reported working an average of more than 35 hours per week. However, meeting an average weekly threshold does not necessarily mean workers can consistently satisfy the requirement every month.

Many Medicaid recipients work in lower-wage industries such as retail, hospitality, food service, healthcare, and agriculture, where schedules can be unpredictable and hours may fluctuate considerably. Workers may also face difficulties involving transportation, affordable childcare, health problems, or limited control over their schedules. These circumstances can make maintaining and documenting 80 hours of qualifying activity each month difficult even for people who are regularly employed.

Researchers analysed federal social and economic data from 2023 to 2025 covering non-elderly adults who were plausibly eligible for Medicaid across the 40 Medicaid expansion states and Washington, DC. They identified people whose weekly hours were close to the 20-hour threshold or whose reported hours varied substantially from their usual schedules. Risk also differed considerably among states, reflecting variations in employment patterns and working conditions.

Demographic differences were also evident. Women had a 22 percent higher probability of insufficient or inconsistent work hours than men, while married enrollees had an 18 percent lower probability of noncompliance than unmarried adults. People with higher education levels faced lower risks than those without a high school diploma. Eligible Black and Hispanic recipients also showed lower risks of noncompliance than eligible White recipients. Single mothers with children aged 14 or older could be particularly vulnerable because the parental exemption generally applies only to parents of younger children or children with recognised disabilities.

The researchers cautioned that their estimates may understate the number of people affected. States must examine at least the previous month of qualifying activity when determining compliance before a Medicaid application and may review as many as three months. Longer look-back periods could make eligibility particularly difficult for people with fluctuating schedules, gig work, part-time employment, or newly obtained jobs, potentially delaying access to Medicaid and widening disparities among workers with unstable hours.

More information: Paul Shafer et al, Medicaid Work-Reporting Requirements Under HR 1 and Insufficient or Inconsistent Work Hours, JAMA Health Forum. DOI: 10.1001/jamahealthforum.2026.2938

Journal information: JAMA Health Forum Provided by Boston University School of Public Health