Millions of Medicaid enrollees may face coverage loss in January 2027 if new work requirements take effect as planned.
getty
A pivotal change is looming in American healthcare. Starting January 1, 2027, millions enrolled in Medicaid must document 80 monthly hours of work, job training, education, or community service to retain their health coverage. However, a survey by The Health Management Academy reveals that more than half of these enrollees are unaware of the impending requirements.
Conducted in April 2026 among 1,974 Medicaid enrollees, the survey highlights a significant gap in awareness. This comes as the Congressional Budget Office forecasts the largest reduction in federal Medicaid spending in the program’s history.
This situation presents pressing concerns, not only about policy communication but also about the potential impacts on patients, hospitals, and healthcare systems if coverage is widely disrupted.
More Than Half Unaware of New Medicaid Work Requirements
The survey asked participants if they knew about the requirement to complete 80 hours per month of qualifying activities for Medicaid eligibility by January 2027. Alarmingly, 55% were completely unaware, 27% had heard something but were unclear on details, and only 17% were informed about the requirement.
Moreover, 85% of respondents were unaware that eligibility checks would change from annually to every six months. These adjustments are part of Trump’s One Big Beautiful Bill Act signed into law on July 4, 2025.
These findings underscore a major communication challenge for state Medicaid agencies, which must initiate enrollee outreach by June 30, 2026, and complete initial outreach by August 31, 2026. The Department of Health and Human Services is expected to issue an interim final rule by June 2026, yet many states have not begun messaging.
Historically, communication has been difficult. For example, when Arkansas introduced Medicaid work requirements in 2018, a Harvard survey found that over 70% of affected residents were unsure about the policy, despite extensive outreach efforts.
Loss of Coverage Due to Medicaid Work Requirements
Arkansas’s experience with Medicaid work requirements resulted in about 18,000 people losing coverage in its first year, primarily due to paperwork issues rather than a lack of work.
The survey further explored how enrollees would respond to losing Medicaid coverage. Among those with chronic health conditions, 62% said they would ration or stretch medication, 58% would stop filling prescriptions, and 55% would forgo specialist appointments.
When considering which medications to stop first, mental health drugs were at the top (25%), followed by blood pressure and cholesterol medications (22%), and diabetes medications (17%).
Clinically, abruptly stopping medication can be risky. For example, discontinuing antidepressants or anxiety medications can worsen conditions or cause dangerous withdrawals. Stopping antihypertensives and statins can increase heart risks and lead to emergencies, while discontinuing diabetes medications can cause hyperglycemic crises.
ERs Poised to be Last Resort for Coverage Loss
According to the survey, 37% of respondents would wait until health issues became urgent to seek care in the ER if they lost coverage, while 28% would use the ER for routine care. Nearly two-thirds of those with chronic conditions would rely on the ER in such circumstances.
Emergency physicians are familiar with this pattern, as ERs often serve as the safety net for patients without other options. Under the Federal Emergency Medical Treatment and Active Labor Act (EMTALA), ERs must evaluate and stabilize all patients, regardless of payment ability.
The survey suggests a potential rise in uncompensated ER visits, coinciding with financial strains on hospitals expected to handle these visits. An April 2026 analysis showed 446 hospitals in 44 states at high risk of closure or service reduction due to Medicaid funding cuts.
Impact on Racial Disparities by Medicaid Work Requirements
Survey subgroup analysis highlights concerns about health equity. Black enrollees had the highest unawareness rate of work requirements at 62%, compared to 56% of White and 54% of Hispanic enrollees, and were most likely to be unable to travel if their hospital closed.
Transportation access exacerbates these risks. Overall, 62% of respondents do not drive to medical appointments, relying on other means. In urban areas, 73% do not drive, and 45% cannot travel farther for care. In rural areas, distances and transportation options present challenges.
Older enrollees, especially those 65 and older, are more vulnerable, with less awareness of changes and a higher likelihood of rationing medication compared to younger adults.
Strategies for Health Systems on Medicaid Work Requirements
Healthcare systems must act before enrollment disruptions begin. Community health workers and care teams should identify high-risk Medicaid patients, particularly those with chronic conditions like mental health and diabetes. Outreach about the new law’s requirements and implications should start immediately.
Systems with significant Medicaid payer mixes will face direct revenue impacts, including fewer covered visits, more uncompensated ER care, and higher patient acuity due to deferred treatment. Health systems should prepare scenarios for volume and revenue impacts.
HMA’s survey indicates that upcoming state outreach will reach a largely uninformed population. Many enrollees will be surprised to find their coverage depends on documentation that may be difficult to provide.
The Congressional Budget Office estimates 5.3 million Medicaid beneficiaries could lose coverage by 2034 due to the new work requirements.
This survey serves as an early warning. The challenge is for state agencies, health systems, and advocacy groups to engage at-risk individuals to prevent coverage loss, especially among the most vulnerable.
