Between 5 and 10 million people could lose Medicaid coverage in 2028 due to changes from the One Big Beautiful Bill Act, depending on the steps states take to mitigate coverage losses, according to a new report.
The analysis, published last week, was conducted by the Urban Institute with support from the Robert Wood Johnson Foundation. It uses the Urban Institute’s health insurance policy simulation model to project enrollment losses due to the Act’s requirement to show proof of work to maintain coverage, as well as the requirement to redetermine eligibility every six months.
The report shows that the way states roll out these new provisions — such as whether or not they increase automatic determinations and reduce paperwork requirements — could lead to big differences in the number of people who lose coverage. To represent this, researchers provided results for high, medium and low mitigation scenarios.
The researchers found that in high mitigation scenarios, enrollment could drop by 27%, versus 55% in low mitigation scenarios. Enrollment will decline in all 41 states (including D.C.) that expanded Medicaid under the Affordable Care Act.
The researchers also found that between 2 and 3.1 million people will lose coverage due to their eligibility being redetermined more frequently. And after accounting for more frequent eligibility checks, between 3 and 7 million people will lose Medicaid coverage due to work requirements.
In addition, between 19% and 37% of people already working will still lose Medicaid coverage due to challenges proving that they’re meeting requirements, the researchers noted.
“Even in a best-case scenario, work requirements will cause millions of people to lose their Medicaid coverage, and if states do not implement the law with care, that number could double,” said Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, in a statement. “Among the most affected will be older adults, the self-employed, and those with physical and mental health conditions.”
As for how states can minimize coverage losses, they can take steps to automatically verify work, income and other eligibility factors instead of relying on paperwork. They can also apply more flexible exemptions to work requirements, such as for caregivers or those with chronic conditions. In addition, states should simplify reporting requirements and invest in user-friendly systems and outreach, the report stated.
CMS can also take steps to mitigate coverage losses, according to the analysis. These steps include issuing clear and flexible guidance on work requirements and strengthening oversight by reviewing state implementation plans. They can also require robust reporting of enrollment, and pause disenrollments if data shows eligible populations are losing coverage due to system failures.
Still, even with these steps, millions of people will lose coverage under the One Big Beautiful Bill Act, according to the Urban Institute.
“This will include many who are meeting or exempt from work requirements but have difficulty submitting the necessary paperwork,” said Matthew Buettgens, senior fellow at the Urban Institute. “The Medicaid coverage of several million people will depend on state implementation choices and federal guidance that help ensure that people are not wrongfully denied coverage or disenrolled.”
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