The One Big Beautiful Bill Act (OBBBA) includes several provisions that will make it harder for adults to enroll in and maintain coverage through the Affordable Care Act Medicaid expansion in 41 states (including the District of Columbia). These include establishing work requirements (also called community engagement requirements) and doubling the frequency of eligibility redeterminations to every six months instead of annually. We assess characteristics of young adults ages 19 to 24 who would be subject to these policies in 2028 and project their changes in expansion coverage nationally and by state.

Why This Matters

Prior analysis has found that most adults enrolled in Medicaid expansion coverage are either engaged in activities prescribed under work requirements or could meet exemption criteria. But many could face difficulties navigating these processes, and states may face challenges deeming people as meeting the requirements if data on their compliance and exemption activities are not available or if they cannot reach enrollees for information. Young adults may struggle to retain Medicaid coverage under these new requirements because of their high rates of residential mobility and participation in community engagement activities, like school attendance and gig work, that are not readily captured in state data. Medicaid coverage loss among young adults would, in turn, reduce their access to health care, which could inhibit identification of health issues that emerge during this period, management of chronic health concerns, and ongoing care during a time of continued brain development.

Key Takeaways

• Many expansion-enrolled young adults have characteristics that would make them compliant with or exempt from OBBBA’s work requirements, but such information may not be readily available in state data. Eighty-eight percent of young adults with expansion coverage have one or more characteristics that could be used to demonstrate compliance with or exemption from work requirements. Eighty percent would meet OBBBA’s income standard or be enrolled in an education program, which could be used to show compliance with OBBBA’s work requirements. Others could be exempt from the requirement, such as the 12 percent who are in fair or poor health or report a functional limitation, some of whom may meet the law’s definition of being medically frail. However, data available to states to automatically assess these characteristics may be limited, meaning many young adults may have to report or provide documentation about their characteristics.
• OBBBA and six-month redeterminations could reduce young adult Medicaid expansion enrollment by 22 to 48 percent, or 1.1 to 2.3 million, in 2028, depending on state implementation. We modeled high-, medium-, and low-mitigation scenarios that assess expected impacts depending on how actively states work to mitigate coverage losses among those who meet the requirements. We found that Medicaid work requirements and more-frequent eligibility checks could reduce young adult Medicaid expansion enrollment by 22 percent under a high-mitigation scenario that assumes every state makes policy and implementation choices that maintain coverage for many people who meet the requirements, or by 48 percent under a low-mitigation scenario that assumes every state makes policy choices that lead to higher enrollment losses. This means there would be 1.1 to 2.3 million fewer expansion enrollees in this age group in 2028, depending on state implementation choices. Although most of the overall coverage decline we project is because of work requirements, more-frequent redeterminations will also contribute.
• Medicaid expansion coverage is projected to fall among young adults in every expansion state. We project coverage losses across states ranging from 9 to 31 percent in a high-mitigation scenario and from 22 to 58 percent in a low-mitigation scenario.
• Implementation choices will be critical for minimizing Medicaid expansion drops among young adults. The size of young adults’ Medicaid coverage losses will depend on how effectively states mitigate coverage risks through their policy choices, with the number projected to lose coverage over twice as high under a low-mitigation scenario compared with a high-mitigation scenario. This highlights the importance of state decisions such as how extensively states use automatic data-matching to assess eligibility and determine compliance with and exemption from work requirements and how effectively they provide outreach and education about new policies and targeted assistance to young adults with applications and redeterminations.

How We Did It

We use the Urban Institute’s Health Insurance Policy Simulation Model to assess characteristics of young adults ages 19 to 24 who would be subject to OBBBA’s work requirements and six-month redeterminations in 2028 and project their coverage declines nationally and by state. We build on an earlier model that has been updated to reflect recent federal guidance (such as related to how income, medical frailty, and caregiving will be defined under implementation of work requirements) and other newly available information.

Because states will vary in how they implement these provisions, and in their administrative approaches and capabilities, we present a range of estimates reflecting the extent to which states help eligible individuals maintain coverage: (1) a high-mitigation scenario that assumes every state makes policy and implementation choices that maintain coverage for many people who meet the requirements; (2) a low-mitigation scenario that assumes every state makes policy choices that lead to higher enrollment losses, such as less data-matching to determine who meets the requirements; and (3) a medium-mitigation scenario between these two.