In a recent analysis applying lessons from two states with prior Medicaid work requirements, we estimated that about 5 million Affordable Care Act expansion adults could lose Medicaid coverage in 2026 under a federal work requirement policy with provisions like the Limit, Save, Grow Act of 2023 (Karpman, Haley, and Kenney 2025). Our analysis of the Urban Institute’s Health Insurance Policy Simulation Model data for 2026 estimated that 4.6–5.2 million of the projected 13.3 million expansion enrollees ages 19 to 55 nationally would lose federally funded Medicaid, with the range indicating the expected coverage losses that would occur if enrollee reporting patterns followed those observed in Arkansas and New Hampshire, respectively. Though over 9 in 10 expansion adults ages 19 to 55 already work, participate in work-related activities, or could meet exemption criteria, many would lose coverage because of low awareness and understanding of the policy and difficulty using state reporting systems.
Here, we describe how these projected coverage losses would be distributed across the 40 expansion states and the District of Columbia (table 1). We find that thousands of expansion adults in each state could lose Medicaid if the patterns observed under prior work requirements apply to all states, likely resulting in greater unmet health care needs, rising medical debt, and worse health outcomes.
If implementation experiences follow those in states with prior Medicaid work requirements, at least 10,000 adults would lose coverage in nearly every expansion state; losses would number over 100,000 in 13 states.
Potential coverage losses would be highest in states with large populations like California (1.0–1.2 million) and New York (743,000–846,000), would number over 100,000 in Arizona, Illinois, Indiana, Kentucky, Louisiana, Michigan, New Jersey, North Carolina, Ohio, Pennsylvania, and Washington State, and would be at least 10,000 in nearly every expansion state. Variation in coverage losses across states reflects variation in the projected size and composition of each state’s expansion population in 2026.
Most adults at risk of coverage loss are already engaged in work activities or could meet exemption criteria.
More than 9 in 10 expansion adults ages 19 to 55 nationally are already working some or all months of the year, are parents or caregivers for children under 18, attend school, are looking for a job, care for a disabled household member, or are in fair or poor health or have a functional limitation, indicating that many would lose coverage despite being engaged in activities prescribed under work requirements or meeting exemption criteria. Experiences in Arkansas and New Hampshire indicate that coverage loss under work reporting requirements often results from difficulty navigating state reporting processes, including obtaining exemptions and reporting qualifying activities, rather than a lack of work effort.
In practice, state enrollment losses could vary widely based on state capacity and implementation of work requirements, as well as how legislation and federal guidance are designed.
Besides assuming work requirements would only apply to expansion enrollees ages 19 to 55 and include provisions of the Limit, Save, Grow Act, we assume states would use available data to automatically exempt enrollees from reporting requirements like Arkansas and New Hampshire did under prior waivers. However, some states may develop additional data-matching strategies to identify more adults as exempt or compliant, while other states may lack this data system capacity and see higher enrollment losses. States could also vary in their processes for obtaining an exemption or reporting work activities for adults who are not automatically deemed exempt or compliant. State coverage losses would also depend on the law’s specifications, what the Centers for Medicare & Medicaid Services (CMS) would allow or prohibit in terms of states’ operational choices, and how much CMS would hold states accountable for maintaining enrollment among people who should be exempt or are meeting the work requirement.
