During sweltering summer days, DeAnna Brandon enjoys watching her three dogs run around while she cools off in a backyard kiddie pool alongside her grandchildren. The 48-year-old blood cancer survivor treasures these precious moments — while questioning whether she’ll experience them in future years.
Brandon, a Rockwell, North Carolina resident, fears that upcoming Medicaid work requirements beginning next year might threaten her healthcare coverage. While she anticipated qualifying for a medical frailty exemption, fresh guidance issued by President Donald Trump’s administration last week has created uncertainty about her eligibility.
The interim final rule published by the Centers for Medicare and Medicaid Services indicates that Brandon’s severe fatigue and memory problems from her treatments might not suffice to avoid the new work requirements. She must declare and subsequently demonstrate that these symptoms “significantly impair” her capacity to meet the new mandates.
Should the government reject her application, she risks losing her coverage — along with the bi-monthly maintenance chemotherapy that maintains her multiple myeloma in remission. Employment remains “outside of the realm of possibility for me,” she explained during an interview.
“I was always a push-through-it person — you know, ‘Oh, you’re tired. Push through,’” Brandon stated. “It’s hard to explain to people you can’t push through it.”
Healthcare analysts have raised concerns about the Republican Trump administration’s latest guidance, which diverges from state expectations. Specialists warn it will increase the number of Americans at risk of losing health insurance and force states to scramble in their already rushed implementation efforts.
“This will mean more paperwork for Medicaid patients — specifically for the sickest Medicaid patients,” stated Adrianna McIntyre, a professor at Harvard University’s school of public health. This development, she noted, “is going to push in the direction of more people needlessly losing coverage.”
The new Medicaid restrictions formed part of Trump’s comprehensive tax and policy law in 2025. The modification impacts those covered through an expansion that most states adopted, providing additional lower-income individuals access to the government’s safety net healthcare program.
Expansion participants between ages 19 and 64 must demonstrate they work or perform community service for at least 80 hours monthly or attend school at least half-time. Exceptions exist for those deemed medically frail or enrolled in addiction treatment programs, among other categories.
Last week’s CMS announcement surprised states with a revised definition of medical frailty. The law had specified that medically frail individuals include those with substance use disorders, disabilities or serious medical conditions. However, the CMS rule went beyond this, stating someone’s condition must “significantly impair” their capacity to work, volunteer or attend school at required rates to receive an exemption.
During 2027 and once in 2028, patients can declare they meet this definition. However, when seeking coverage renewal in 2028, they must provide proof.
Advocates express uncertainty about what documentation could establish that standard. They suggest physician notes might be necessary — something some providers feel uncomfortable providing. Medicaid participants battling illness may bear the administrative burden.
Brandon, who previously attempted to prove work incapacity for disability benefits during active cancer treatment and was unsuccessful, worries about the obstacles she and fellow patients might face.
“It’s not that easy — you may have to go through four doctors,” Brandon explained. “If you’re already battling an illness like this, you don’t have the physical or the mental or the emotional energy to do that all the time.”
States have planned to utilize Medicaid claims data and additional data sources to automatically exempt qualified participants whenever feasible.
CMS Administrator Dr. Mehmet Oz during a reporter call last week supported this strategy, expressing hope that most individuals would receive assistance “without ever having to talk to anybody.”
When asked to explain rule implementation, CMS informed The Associated Press via email that the agency “chose not to allow states to categorically exclude individuals from work requirements based solely on a diagnosis or condition type.” For 2028 renewal, it stated, “verification through claims data or other documentation will generally be required.”
State Medicaid officials and consultants report that Medicaid claims data cannot prove significant work impairment, and they’re unaware of existing data that does. This has created confusion about complying with the government’s rule.
“States are going to be asked to make a determination using information that doesn’t exist in their systems,” explained Kinda Serafi, a partner at consulting firm Manatt Health who assists states with these changes.
Nebraska began implementing new Medicaid work requirements early. However, it utilized diagnostic codes to identify medically frail individuals, likely requiring system modifications, according to Sarah Maresh, healthcare access program director at advocacy group Nebraska Appleseed.
Maresh expressed concern that rural state physicians already hesitant to accept Medicaid patients might cease participation entirely.
“They’re already drowning in paperwork, so to require them to do an additional step of certifying whether someone is able to work, I think is concerning,” she noted.
Preparing for the January 1 launch represents an enormous and costly undertaking. A $200 million federal allocation supports states, and CMS has collaborated with technology companies to offer free and discounted services, but expenses for additional technology requirements and staffing will likely surpass $1 billion, according to an AP analysis. This additional cost will be shared between federal and state tax dollars.
Republicans supporting the new rules describe them as commonsense measures to eliminate government freeloading and preserve benefits for those most in need. Oz last week, referencing a conservative American Enterprise Institute think tank report, claimed able-bodied Medicaid recipients spend an average of 6.1 hours daily “watching TV or just hanging out.”
“This is a concern, not a criticism,” he stated. “Work requirements are going to turn this around, we hope.”
Current participants who don’t meet work requirement thresholds say this mischaracterizes their experiences.
Mids Meinberg, a 42-year-old freelance writer from New Jersey living with chronic depression and diabetes, said that despite health challenges, he takes pride in establishing a meaningful career. However, his conditions prevent him from working 80 hours monthly. He believes many disabled individuals are “too disabled to work but not disabled enough for the state to think they can’t work.”
Brandon, in North Carolina, wants the government to recognize she’s “not just sitting around wasting time or being a drain on society.”
“I’m pouring into my grandchildren,” she said. “We’re valuable, and we can still contribute to our communities even if it’s not working.”
