One Big Beautiful Bill could impact half of Medicaid beneficiaries

1. In this cross-sectional study, about half of Medicaid beneficiaries would lose coverage if work requirements in the One Big Beautiful Bill were applied nationwide.

2. Beneficiaries at risk of disenrollment were more likely to have low incomes, greater physical and neurological impairments, and difficulties with independent living.

Evidence Rating Level: 3 (Average)

Study Rundown: The One Big Beautiful Bill Act, signed into law in July 2025, implemented requirements for able-bodied adults to work or participate in eligible activities each month to maintain Medicaid coverage. Although these requirements currently apply only to adults in certain states who gained eligibility through Medicaid expansion under the Affordable Care Act, proposals have been made to extend them to all working-age Medicaid beneficiaries nationwide. This national cross-sectional study aimed to estimate the number of adults at risk of disenrollment from Medicaid and assess their functional status and overall physical and mental health. Results indicated that a substantial portion of working-age adults with Medicaid coverage would not meet work requirements if implemented nationwide. These adults were more likely to have low incomes, a high school education or less, and multiple chronic conditions, and a significant proportion had an illness or disability that limited their ability to work. Compared with beneficiaries not at risk, they exhibited higher physical impairment, more neuropsychological impairment, and greater limitations in independent living. Among adults at risk of Medicaid disenrollment, poor physical and mental health were more common than among those not at risk. The generalizability of this study is limited by reliance on self-reported outcomes and the inability to capture all exemption criteria. Nevertheless, the findings suggest that expanding Medicaid work requirements nationwide could disadvantage many beneficiaries, whose functional, physical, and mental impairments may compromise their ability to comply with work requirements.

Click to read this study in AIM

Relevant Reading: Medicaid Work Requirements — Results from the First Year in Arkansas

In-Depth [cross-sectional study]: This cross-sectional study estimated the number of Medicaid beneficiaries at risk of disenrollment if work requirements were expanded nationwide and assessed their functional status and overall health. Data were drawn from the 2022–2023 Medical Expenditure Panel Survey, including adults aged 19–64 enrolled in Medicaid. Individuals meeting exemption criteria—such as receiving Supplemental Security Income, dual enrollment in Medicare, caregiving, attending school, or identifying as Native American—were excluded. Beneficiaries were considered at risk if unemployed or working less than 20 hours per week and not otherwise exempt. Among 2,140 adults included (weighted population 16,467,580; mean age 40.5 years; 54.4% female), an estimated 50.4% would not meet work requirements and be at risk of disenrollment. At-risk beneficiaries were more likely to have incomes below 200% of the federal poverty line, a high school education or less, and multiple chronic conditions; 33.5% reported an illness or disability limiting work. Physical impairment was significantly higher among at-risk adults, with severe impairment nearly three times more common (12.4% vs. 4.5%). Neuropsychological impairment was also more prevalent, including mild (15.4% vs. 9.4%) and moderate-to-severe (12.5% vs. 3.4%) impairment. Independent living limitations were higher, with iADL assistance needed by 6.2% vs. 1.2% and ADL assistance by 3.5% vs. 0.2%. Difficulty doing errands alone (11.5% vs. 1.4%) and dressing or bathing (6.4% vs. 1.5%) were more common among those at risk. Poor physical health was reported by 32.7% of at-risk adults, poor mental health by 28.2%, and both simultaneously by 12.3%, all higher than those not at risk. Subgroup analyses showed larger differences among men and older adults. Overall, expanding Medicaid work requirements nationwide would place roughly half of beneficiaries at risk of losing coverage, disproportionately affecting those with functional impairments, poor physical or mental health, and difficulties with independent living.

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