State-by-state estimates of Medicaid expansion coverage losses for 19 to 55 year
Greetings—
We are following up on our previous email about the impact of a mandatory federal work requirement policy on Medicaid coverage loss. A new state-by-state analysis from Urban Institute researchers finds that thousands of adults enrolled in the Affordable Care Act’s Medicaid expansion could lose coverage in each expansion state.
Nationwide, about 5 million expansion adults ages 19-55 could lose Medicaid coverage in 2026 under a mandatory federal work requirement policy. When analyzing how these projected coverage losses would be distributed across the 40 Medicaid expansion states and the District of Columbia, they find:
If implementation experiences follow those in states with prior Medicaid work requirements, at least 10,000 adults would lose coverage in nearly every expansion state. Potential coverage losses would be highest in states with large populations like California (1.0 to 1.2 million) and New York (743,000 to 846,000), and would exceed 100,000 in Arizona, Illinois, Indiana, Kentucky, Louisiana, Michigan, New Jersey, North Carolina, Ohio, Pennsylvania, and Washington State.
Most adults at risk of coverage loss are already engaged in work or work-related activities or could meet exemption criteria. Experiences in Arkansas and New Hampshire indicate that coverage loss under work reporting requirements often results from difficulty navigating state reporting processes, including obtaining exemptions and reporting qualifying activities, rather than a lack of work effort.
State enrollment losses could vary widely based on state capacity and implementation of work requirements, as well as how legislation and federal guidance are designed.
Read the full analysis and previous report to learn more. If you have questions for the research team, please reply to this email. We’re happy to connect you.
Greetings—
A new report from Urban Institute researchers assesses the impact of a proposal to establish nationwide Medicaid work requirements for adults enrolled in the Affordable Care Act’s Medicaid expansion.
The analysis examines potential coverage losses under work requirements modeled on the Limit, Save, Grow Act, a bill passed by the House in 2023 that seems to be a starting point for current congressional discussions. That bill would have withheld federal funding for Medicaid expansion enrollees ages 19 to 55 who did not report working or participating in a work-related activity for at least 80 hours per month, unless they qualified for and obtained an exemption.
Drawing on lessons from Arkansas and New Hampshire, two states with prior experience implementing Medicaid work requirements for their expansion populations, the researchers estimate:
Between 4.6 and 5.2 million expansion adults ages 19 to 55, about 34 to 39 percent of all expansion enrollees in this age group, would lose federally funded Medicaid in 2026 under such a federal work requirement if exemptions and reporting follow previous state experiences.
More than 9 in 10 expansion adults ages 19 to 55 are either engaged in activities prescribed under the policy or could meet exemption criteria. Experiences in Arkansas and New Hampshire suggest that noncompliance with work requirements is rooted in low awareness or understanding of the policy, reporting challenges and confusion related to state notices, limited job opportunities, and employment barriers rather than a lack of work effort or community engagement.
If work requirements are not explicitly limited to the Medicaid expansion population, more than 30 million adults ages 19 to 55 could be subject to them, and the loss of Medicaid would be substantially higher. Coverage losses could vary widely across states based on whether they automatically deem enrollees to be exempt or compliant using available state databases.
The researchers expect Medicaid work requirements to increase the number of uninsured adults, leading to worse health outcomes, financial impacts to health care providers, and higher costs for states.
Read the report and fact sheet to learn more. If you have questions for the research team, please reply to this email.
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