Work requirements, redetermination could mean a 55% decrease in Medicaid enrollment, an Urban Institute study finds

Work requirements and new redetermination requirements could slash the number of people covered by Medicaid by more than 55% in 2028, from 18.4 million to 8.3 million, according to a new Urban Institute study.

The work requirements and determining eligibility every six months instead of annually were among the most significant healthcare provisions in the One Big Beautiful Bill Act that President Donald Trump signed into law in July 2025. The law mandates that states implement the work requirements by 2027.

The Urban Institute researchers analyzed the effects of work requirements and redeterminations in scenarios in which states would make concerted efforts to mitigate the effects of work requirements and redeterminations by, among other things, using existing data to determine eligibility automatically and applying broader definitions of frailty that exempt people from work requirements. They compared the effect on Medicaid enrollment under that “high mitigation” scenario to the effects in “low” and “medium” mitigation scenarios in which states don’t take as many steps to blunt the effect of work requirements and redetermination.

In the high mitigation scenario, average monthly enrollment nationwide would decrease by 4.9 million in 2028, which works out to be a 27% reduction from projected enrollment in 2028 of 18.4 million, according to the Urban Institute report. With medium mitigation, the researchers’ model projects an enrollment decrease of 8.0 million, a 43% decrease, and in low mitigation circumstances, the projection is a decrease of 10.1 million, or a 55% reduction in enrollment. Of course, all these figures are at this point theoretical, not actual, numbers that come from models created by the Urban Institute researchers.

The Urban Institute researchers’ calculations show that the bulk of the enrollment decreases would come from the implementation of work requirements: a 3.0 million decrease in the high mitigation scenario, a 4.9 million decrease in the medium mitigation one and a 7.0 million decrease in the low mitigation one But increasing the frequency of eligibility determination would also have an effect: a 2.1 million decrease in the high mitigation scenario and a 3.1 million decrease in both the medium and low mitigation scenarios.

The work requirements and redetermination requirements apply to adults ages 19 to 64 who have Medicaid coverage because of Medicaid expansion under the Affordable Care Act (ACA). Forty states, plus the District of Columbia, have expanded Medicaid under the ACA. People can meet the work requirement by working80 hours per month or participating in some kind of job training program. Enrollment in an education program at least half time or community service can also used to meet the requirement. Certain groups of people are exempt from the requirements, including American Indians and Alaska Natives; parents, guardian or caretaker relatives of children 13 and younger, a those who are medically frail or have special needs — a list that includes but is not limited to blindness, substance use disorder or a disabling mental disorder. States must implement work requirements in 2027 but can start earlier. According to the Urban Institute, only Nebraska has done so with plans to implement requirements in May 2026.

Other researchers have also put together projections about the effects of work requirements on Medicaid enrollment. According to today’s Urban Institute report, the Congressional Budget Office estimated that Medicaid enrollment would decrease by 5.7 million 2034. Rand researchers projected that Medicaid enrollment would decline by 5.3 million by 2034.

Although the federal government sets overall policy, states set Medicaid policy and implementation. For that reason, the Urban Institute researchers also made state-by-state projection. Their calculations show that in the low mitigation scenario, eight states (Connecticut, Massachusetts, Maryland, Minnesota, Missouri, New York, Vermont and Wisconsin) will see their Medicaid enrollment decrease by 60%. In the high mitigation, six states (Connecticut, Massachusetts, Maryland, New York, Virgina and Vermont) would experience declines of more than 30%.