New Study Reveals High Disease Burden Among At-Risk Medicaid Beneficiaries

Over 40% of the 5 million people at risk of losing Medicaid coverage due to new eligibility requirements have at least three chronic health conditions, and older adults are especially vulnerable, a new JAMA study shows.

Signed into law on July 4, HR 1 makes significant changes to Medicaid, including the establishment of new work requirements. Previous Yale-led research has shown that Medicaid recipients who do not meet work requirements have disproportionately worse health than those who do.

In the new study, Yale School of Medicine (YSM) researchers used data from the U.S. Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey (NHANES) to dive deeper into understanding the clinical characteristics of those at-risk of disenrollment. Their analyses confirmed that the prevalence of chronic disease is high among this cohort, especially for adults between the ages of 50 and 64.

“It’s important to see the real-world impact of legislation that is passed,” says Alissa Chen, MD, MPH, instructor of internal medicine at YSM and the study’s senior author. “We’re seeing that people who are not meeting work requirements have quite high medical needs.”

The new Medicaid work requirements, which will be implemented Jan. 1, 2027, will require recipients to work or volunteer for at least 80 hours a month or be enrolled in a school or training program to keep their coverage. Those who are pregnant, care for a dependent child, or are considered “medically frail” are exempt.

NHANES collects detailed health data from a representative sample of the U.S. population. The survey also includes occupational information such as employment status. “Using this, we were able to pinpoint the subpopulation of people on Medicaid who are not exempt from work requirements,” says Ashwin Chetty, a medical student at YSM and the study’s first author.

The researchers found that two-thirds of at-risk Medicaid recipients are women; 41% have three or more chronic conditions; and over half are taking between one and four prescription medications. For adults between 50 and 64, 66% have at least three chronic conditions and 62% take between one and four prescriptions; one in five takes at least five prescriptions.

“The work requirements as they are going to be implemented are going to adversely affect people who desperately need Medicaid,” says Chen.

Furthermore, the researchers found that the majority of adults who don’t meet work requirements are either already working but do not meet the 80 hour per week threshold or are searching for work.

The researchers state that the consequences of work requirements may be more extensive than their study reports. Arkansas became the first state to implement work requirements in 2018 before being halted by a federal judge the following year. Research on the impact of this legislation shows that it was not associated with changes in employment status, but was linked to significant declines in health care access, even though the vast majority of the study population met the requirements for coverage or qualified for an exemption.

The administrative barriers posed by work requirements can prevent individuals from maintaining coverage, even when they are eligible, the experts explain. “Doing paperwork is an onerous process, and its very existence causes people to lose Medicaid,” says Chen. “Proving you are eligible is a whole process that people generally do not successfully complete.”

Medicaid recipients may be exempt from work requirements if they are “medically frail.” The U.S. Centers for Medicare & Medicaid Services grants states flexibility in determining their own definitions of medical frailty. One administrative barrier, a previous Yale-led study found, is that these definitions often underestimate beneficiaries’ medical inability to work.

The new study sheds light on potential approaches for mitigating the loss of health care access, the researchers say, including informing states on how to define medical frailty. For example, because Medicaid recipients between the ages of 50 and 64 have a particularly high prevalence of chronic medical conditions, expanding the definition to include this age group could reduce the burden of disease in this population.

The researchers argue that this approach may save the federal government money in the long run. “The population of people between 50 and 64 is particularly vulnerable,” says Chetty. “Medicare could end up spending more money taking care of chronic conditions that have gone untreated because people lost Medicaid due to work requirements.”

How policymakers implement work requirement programs will vary across each state. Studies like this one will help researchers more fully understand the consequences such legislation has for public health. “A lot of these policies have good intent,” Chen says. “But analyses like ours show how they are going to affect the health of our nation.”