The changes will cut about $1 trillion from federal Medicaid spending over 10 years

More than 66% of applicable Medicaid recipients are in the labor force, but getting sufficient work hours to qualify for new rules may be a challenge, a study found.

More than 10 million Americans could lose Medicaid health insurance under new work rules that begin in January - putting additional burden on people who have already retired and left the workforce, those in rural areas, and even those who are working but can't get enough hours to meet the minimum to qualify.

Under H.R. 1 - also known as the One Big Beautiful Bill Act - which was signed into law last year, low-income Americans ages 19 to 64 must meet mandatory federal work requirements in order to obtain and keep Medicaid coverage through the Affordable Care Act expansion. That means that these adults must work or participate in community service for at least 80 hours a month or be enrolled in an educational program at least half of the time. There are exemptions for being a parent to young children, serving as a caregiver or being medically frail.

Prior to H.R. 1, there was no federal work requirement, and states wishing to test work requirements had to submit a waiver request to the Centers for Medicare & Medicaid Services.

The changes will cut about $1 trillion from federal Medicaid spending over 10 years. The cuts are part of the Trump administration's efforts to offset the extension of tax cuts, and to curtail spending and eliminate fraud.

While the administrative burden associated with meeting and maintaining these work requirements is expected to be the primary driver of people losing Medicaid, a recent study in JAMA Health Forum found that 1 in 5 enrollees may lose their health coverage because they are unable to get enough work hours. That's 2 million people who are employed but still can't meet the work requirements.

Without health insurance, those millions of people are expected to suffer from a lack of healthcare access, endure worsening health outcomes and experience increased financial distress. Ultimately, the uninsured will likely turn to costly emergency-department visits - and unpaid bills absorbed by hospitals - rather than preventative care and chronic-disease management under Medicaid.

The JAMA study found that more than 66% of applicable Medicaid recipients were already in the labor force; among that group, over 85% were working over 35 hours on average. There are many hurdles, however, to consistently completing and proving the 80 hours of work per month needed, the researchers said.

Many Medicaid recipients work low-wage jobs in the retail, hospitality, food-service, healthcare and agriculture industries, which means they face inconsistent and unpredictable work hours and positions.

Medicaid benefits vary by state, but federal law requires coverage of inpatient and outpatient hospital services, doctor visits, lab tests, X-rays, home health services and other benefits.

"Working in low-power jobs means they have low flexibility and low control over their schedules," said David Anderson, the study's senior author and an assistant professor at the University of South Carolina's Arnold School of Public Health. "A lot of times, you can't control what happens to your schedule or shift, and you lose hours through no fault of your own."

These low-income workers also often face challenges with transportation and childcare, and may have unrecognized disabilities or chronic health conditions that make it difficult for them to consistently complete job requirements each week, Anderson and his co-authors found. There's also a trend toward replacing service workers with technology, making it harder to get shift work, they noted.

States will look back through at least one month and up to three months of work records to determine if someone is eligible to get or keep Medicaid.

"We're not trying to be alarmist, but there's a substantial number of people who will be losing coverage," said Paul Shafer, the study's lead author. Shafer is an associate professor of health law, policy and management at Boston University's School of Public Health, and co-director of BU's Medicaid Policy Lab.

Overall, women had a 22% greater chance of having insufficient or inconsistent work hours than men, the study found. Single mothers with children over the age of 14 may be among those hit the hardest by the new work rules, it added.

There are other pockets of Americans who will likely lose Medicaid benefits under the new rules, according to analysts. Gig workers and self-employed workers may have a harder time proving their work hours to meet the requirements. Rural Americans who face transportation issues, as well as insufficient job availability, also are at risk.

Another particularly vulnerable group are people ages 50 to 64 who retired from a job and receive Medicaid, who will now need to go back to work to retain eligibility, analysts said.

"They may be retired because they developed health conditions, or they worked construction or another heavy, labor-intensive job and just couldn't do that work any more. They left the workforce, and now it's unclear if they can get back in," said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a healthcare-policy research firm.

"If you're an older adult over 60, employers are less likely to want to hire you," Tolbert said. "This group of people who are retired will face unique and difficult challenges going back to work."

-Jessica Hall