A sweeping new report warns that millions of Americans could lose their Medicaid coverage in the coming years. The findings have alarmed health advocates, hospital administrators, and policy experts across the country. At the heart of the issue are new work requirements and more frequent eligibility checks — both introduced through the One Big Beautiful Bill Act, signed into law on July 4, 2025.
What the Report Reveals
A new analysis by the Urban Institute and the Robert Wood Johnson Foundation estimates that as many as five to ten million Americans could lose Medicaid coverage by 2028. This figure represents a wide range because the actual impact depends heavily on choices made at the state level.
Researchers modeled enrollment impacts under high, medium, and low mitigation scenarios — each reflecting how actively states work to minimize the number of people losing coverage. Therefore, the outcome will vary significantly from state to state.
Furthermore, the Congressional Budget Office projected that the legislation would reduce Medicaid enrollment and cause millions of people to become uninsured by 2034. These projections underscore the scale of what lies ahead.
How Work Requirements Drive Coverage Loss
The New 80-Hour Monthly Rule
The One Big Beautiful Bill Act conditions Medicaid expansion coverage on whether beneficiaries work, volunteer, or participate in work-related activities for 80 hours per month — or are enrolled in school at least half time — unless they qualify for an exemption.
New applicants must prove compliance before enrolling. Additionally, existing enrollees must demonstrate compliance at every eligibility redetermination. This creates a significant administrative burden for millions of people.
Paperwork Problems, Not Ineligibility
Critically, most people who lose coverage will not lose it because they are ineligible. Instead, they will lose it because they fail to navigate complex paperwork requirements. Harvard researchers note that the more frequently people must go through an application or reporting process, the more likely they are to fail to navigate it successfully — even if they are legitimately employed or exempt.
Matthew Buettgens of the Urban Institute noted that many who qualify for Medicaid — including some already meeting work requirements — may struggle to submit the needed paperwork. As a result, coverage losses may reflect administrative failure rather than actual ineligibility.
Frequent Eligibility Checks Add to the Risk
Semi-Annual Redeterminations
In addition to work requirements, the new law introduces more frequent eligibility checks. The legislation requires states to verify whether expansion enrollees are still eligible for Medicaid every six months. Previously, annual checks were the standard in most states.
Between two million and 3.1 million people are projected to lose coverage specifically due to these more frequent eligibility redeterminations. This is separate from the losses caused by work requirements.
Together, these two provisions compound the risk for tens of millions of enrollees who already face challenges managing routine administrative tasks.
Who Is Most Vulnerable?
Working Adults Who Still Lose Coverage
Counterintuitively, even people who are already working face the risk of losing coverage. Between 19% and 37% of people who already work will nevertheless lose Medicaid coverage — including those meeting the work requirement but facing challenges documenting their work activity.
Young Adults and Students
Young adults are particularly vulnerable because they are more likely to be students and face challenges achieving stable employment. States are less likely to have data on their work or education that would deem them compliant. Moreover, young adults often struggle to navigate complex government bureaucracy.
Women of Reproductive Age
The new work requirements alone threaten to eliminate Medicaid coverage for an estimated 2.1 million women aged 19 to 49, based on CBO projections of the impact of that provision by 2034. Low-income women, Black and Hispanic women, and young adults are expected to bear a disproportionate share of coverage losses.
Children on Parent Plans
Although work requirements target adults, half of all children in the US are insured through either Medicaid or the Children’s Health Insurance Program — meaning children could also be affected if a parent loses coverage or fails to meet reporting requirements in time.
Impact on Hospitals and Healthcare Access
Emergency Rooms Under Pressure
The coverage losses will not only affect individual patients. Hospitals — especially those in rural and low-income areas — face serious financial pressure as uninsured patient volumes rise. Hospital administrators warn that as more patients arrive uninsured, the revenue to support their care simply will not be there — creating what one CEO called an unfortunate but fairly permanent new reality.
Rural Hospitals at Greatest Risk
Hospitals already at risk of closing face an especially difficult path forward, given that the Rural Health Transformation Program included in the law covers only a fraction of the projected financial losses from Medicaid cuts.
A Cascade of Access Problems
Dr. Georges Benjamin of the American Public Health Association warned that Medicaid cuts will leave more Americans without access to doctors — raising the risk that patients end up in hospitals with advanced conditions that could have been treated earlier. Consequently, prevention and early treatment give way to expensive emergency care.
What States Can Do
State governments hold significant power to cushion the impact. State policymakers are already warning that cuts will lead to benefit reductions, provider pay cuts, and lost coverage for millions — while some governors and state health departments have begun announcing plans to mitigate anticipated budget shortfalls.
Katherine Hempstead of the Robert Wood Johnson Foundation stressed that even in a best-case scenario, work requirements will cause millions to lose Medicaid — but if states do not implement the law carefully, that number could double.
States can also use data-matching systems to ease compliance burdens, expand telehealth coverage, and pursue Medicaid State Plan Amendments to protect access to essential services, including reproductive care.
Conclusion
The scale of predicted Medicaid coverage losses is unprecedented. Millions of Americans — working adults, students, women, children, and people with disabilities — now face the real possibility of losing their health insurance not because they are ineligible, but because of administrative hurdles they cannot overcome. State decisions in the months ahead will determine just how many people fall through the cracks. The stakes for patients, hospitals, and the broader healthcare system could not be higher.
