The following comments were submitted by Richard Besser, MD, president and CEO of the Robert Wood Johnson Foundation (RWJF), in response to the Interim Final Rule regarding the Medicaid Program’s Community Engagement Requirement for Certain Individuals (hereinafter “IFR”) published by the Centers for Medicare & Medicaid Services (hereinafter, “CMS”) in the Federal Register on June 3, 2026.[1]
RWJF is a leading national philanthropy dedicated to taking bold leaps to transform health in our lifetime. Through funding, convening, advocacy, and evidence-building, we work alongside communities, practitioners, researchers, nonprofit organizations, and public institutions to get to health equity faster and pave the way together to a future where health is no longer a privilege, but a right.
Access to quality healthcare is essential to everyone's ability to achieve and maintain good health—and it is not possible without affordable, quality health insurance coverage. For more than 50 years, RWJF has funded research and programs to identify and close key gaps in healthcare coverage and access and to achieve a healthcare system that is fair, just, and built for everyone. RWJF has supported academic research evaluating the impact of Medicaid on the lives of all Americans, including those who qualify for coverage through Medicaid expansion, as well as the impacts of work requirements in Medicaid and other social safety net programs.
For over 60 years, Medicaid has been an important part of America’s social safety net. Medicaid provides affordable health coverage for more than 67 million people with low incomes or disabilities throughout the United States. Research has repeatedly shown that Medicaid coverage leads to better health outcomes for participants—saving lives, lowering health care costs, making childbirth safer, reducing medical debt, and helping strengthen state economies. Medicaid strengthens communities for everyone, even those not covered by the program. It is a bedrock of state and local economies, supporting healthcare jobs and providing vital funding to hospitals, particularly in rural areas.
Our comments on the IFR are grounded in the perspectives and expertise of our grantees, who include nonprofit organizations, researchers, national and state health policy experts, and advocates for Medicaid beneficiaries working to improve healthcare access for people across the United States.
1. Introduction
The IFR rests on the notion that conditioning Medicaid eligibility on a community engagement requirement will “empower” beneficiaries. CMS reasons that employment produces reliable income and financial stability, which—in turn—produces better health, and that work itself is “intrinsic” to wellbeing.[2] CMS claims the work requirement has “the potential to empower Medicaid beneficiaries through employment, education, or volunteer service so they can escape isolation and dependency, build confidence, and achieve self-sufficiency and independence,”[3] and that Medicaid should be “a short-term hand up, not a lifetime handout.”[4]
CMS’s conclusions about the purported health benefits of work requirements are unsupported by research. In advancing these unsupported claims, CMS ignores a robust and consistent body of evidence which establishes that:
- Work requirements in public benefits programs, including Medicaid, do not increase or otherwise promote employment;
- Work requirements cause significant, and often erroneous, coverage loss;
- Those without health coverage are less able to access necessary care and experience worse health, on average, than those with stable coverage.
On the same day the IFR was published, the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) released an issue brief entitled, “Medicaid Work Requirements Incentivize Employment and Are Estimated to Reduce Poverty.”[5] The IFR does not cite the brief directly. However, its reasoning tracks with the brief, and we thus assume the brief informed CMS’s drafting. As discussed below, the ASPE brief itself has already been sharply criticized by former ASPE directors and other public health experts.
We recognize CMS cannot decline to implement a community engagement requirement. Within the confines of that requirement, however, CMS retains meaningful discretion, and it can and should make design choices that promote coverage to the greatest extent possible. CMS has instead relied on the faulty premise that work requirements "empower" beneficiaries—a framing that has led CMS to graft on an excessive amount of administrative burdens to beneficiaries (and states), including requiring individuals considered "medically frail" to affirmatively demonstrate they cannot comply, and significantly limiting the use of self-attestation to prove eligibility for an exemption. Neither choice is compelled by Congress, and each will foreseeably result in erroneous coverage denials and terminations. We therefore urge CMS to reconsider these provisions.
2. Work Requirements Do Not Promote Employment
Research consistently shows work requirements do not increase employment. Work requirements in the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) programs have existed for years and provide a strong basis for predicting the efficacy of work requirements in promoting employment. Those studies show the following:
- Participation in SNAP does not reduce work effort;[6]
- Work requirements do not increase employment;[7]
- Michigan’s tiered TANF “work sanctions”—culminating in a lifetime ban from TANF benefits after three instances of noncompliance with a work requirement—left individuals 13.8 percentage points less likely to be formally employed after two years;[8]
- Work requirements do little to reduce poverty and, in some cases, push families deeper into poverty;[9]
- In Kansas, 70% of parents leaving TANF due to work sanctions often had no earnings or earnings below the deep-poverty level;[10]
- In 2013, only 9.6% of recipients left the TANF program due to finding employment, while almost four times as many individuals (36%) left as a result of sanctions or a failure to comply with the verification and eligibility procedures;[11]
- The majority of TANF enrollees work regardless of whether they are required to do so, suggesting that a work requirement has little impact on increasing employment over the long-term and that enrollees work in low-wage jobs and remain poor despite being employed.[12]
Several states have also attempted to implement work requirements in Medicaid, including in Arkansas, New Hampshire, and Georgia. Research from each state paints a picture similar to that of the impact of work requirements on employment in other public benefits. For example, in Arkansas, the work requirement was associated with significant coverage loss but “no significant change in employment,” including no effect on employment, hours worked, or employer-sponsored coverage.[13] Another analysis of Arkansas’ work requirement implied a reduction in Medicaid coverage of 12 percentage points, accompanied by a significant increase in the uninsurance rate and no significant change in employment, hours worked, or overall rates of community engagement.[14] Further, disenrollment during Arkansas’ work requirement resulted in adverse outcomes including poorer medication adherence, delayed care, and an average of over $2,200 of medical debt for Arkansans who disenrolled from coverage.[15]
CMS’s conclusion to the contrary appears to rest on the ASPE issue brief referenced above. However, as noted in a critique authored by two former ASPE directors, the issue brief is deeply flawed. Those authors ultimately conclude that the brief’s central estimate—that Medicaid work requirements could reduce poverty by 1.6 to 2.9 million people—rests on “completely unrealistic assumptions” and is therefore of “limited use in assessing likely policy outcomes.”[16] In highlighting the brief’s deficiencies, the authors first note that the brief’s literature review relies primarily on welfare-to-work initiatives from the 1990s in TANF and housing programs. The brief does not reference the findings discussed above that are specific to studies of Medicaid work requirements and show coverage losses, adverse health outcomes, and no improvement in employment or hours worked. Additionally, the programs cited by the ASPE brief all involved substantial work support components that are absent from the current Medicaid structure. And the ASPE brief omits any references to a Congressional Budget Office (hereinafter, “CBO”) report from 2023 finding that, in an earlier iteration of Medicaid work requirements proposed in federal legislation, “the employment status of and hours worked by Medicaid recipients would be unchanged….”[17]
In another analysis, researchers expressed grave concern that the ASPE study misrepresents the state of scholarly evidence on the impacts of work requirements.[18] This analysis notes that the ASPE brief omitted research studies that found work requirements led to coverage loss and failed to increase employment[19]
Furthermore, ASPE’s simulation model, which was used to project the impact of work requirements on poverty, is based on incorrect assumptions. The model does not rely on the results of ASPE’s literature review and assumes employment effects inconsistent with the literature it did summarize. The model assumes without evidence that work requirements will cause large numbers of people to enter the labor force, which one critic noted is a “facially absurd approach.”[20]
3. Even If Stable, Higher-Wage Employment Has the Potential to Benefit Health, Medicaid Beneficiaries Have Limited Access to those Types of Opportunities
While employment may promote better health, those health benefits depend on the quality of the job.[21] The quality of employment to which Medicaid beneficiaries have access is low. The labor market available to Medicaid beneficiaries—a disproportionate percentage of whom, if not currently engaged in stable work (i.e., the population that Medicaid work requirements are attempting to target), have an education of a high school degree or less—is predictably characterized by low wages, stagnant wage growth, few prospects for advancement, and volatile, unpredictable hours.[22] This is not the type of employment that promotes financial stability leading to good health. Indeed, the article cited in the IFR to support this contention expressly concludes that “[i]nsecure or low-quality work demonstrated the potential to override identified health benefits of work.”[23]
Critically, these low-wage, unstable jobs are exactly those associated with high-risk occupations and health-impairing working conditions, including hazardous exposures, shift work, and unpredictable hours.[24] “High strain” jobs—heavy workloads with little decisionmaking authority, or little reward or recognition—are affirmatively linked to poor health outcomes such as hypertension and cardiovascular disease.[25] Notably, CMS acknowledges this point. finding that “unemployment and unstable work are linked to poorer health outcomes.”[26]
The IFR aptly states that the relationship between work and health is “bi-directional.”[27] The evidence indicates that healthier people are more likely to find and keep work.[28] That does not mean, however, that requiring work makes people healthy.
CMS cites Chetty et al. (2016) for the proposition that income and financial stability from employment can lead to improved living conditions and increased capacity to engage in healthy behaviors.[29] Yet, that study found that for individuals in the lowest income quartile (i.e., the Medicaid target population), unemployment rates and changes in the size of the labor force were not significantly associated with life expectancy.[30] Two other articles cited by CMS identify income support—not employment per se—as the mechanism linking work and health, recommending income-support programs as a means of promoting financial stability and, in turn, mental and physical health.[31]
Other research explains that it is access to health insurance accompanying stable employment, as opposed to employment standing alone, that accounts for much of the correlation between work and longevity.[32] In other words, it is access to health insurance, not work, that improves health outcomes.
The evidence on mental health leads to similar conclusions. Poor quality and temporary employment is associated with worse mental health. One study found that people who became employed in poor-quality jobs presented poorer mental health than those who remained unemployed.[33] The IFR’s cited research confirms the same.[34]
To the extent CMS relies on volunteering as an activity that counts toward compliance, the benefits of volunteering diminish or disappear when perceived as obligatory, and studies of volunteering are complicated by self-selection because healthier, better-connected people are more likely to volunteer in the first place.[35]
Rigorous evaluations of mandatory welfare-to-work programs confirm the absence of health benefits. A Cochrane systematic review of twelve randomized controlled trials of welfare-to-work interventions (involving 27,482 individuals, eleven trials using North American data) found that any effects on health were “largely of a magnitude that is unlikely to have tangible impacts,” concluding that welfare-to-work “does not have important effects on health.”[36] A separate systematic review of lone parents subject to work requirements found that ten of the included studies reported that participation “exacerbated ill health,” and that participation “may do little to improve lone parents’ health and wellbeing or economic circumstances, often only leading to low paid, precarious employment.”[37]
In fact, the street runs the other way: Medicaid is, in itself, a critical work support. In Ohio’s Medicaid expansion enrollee surveys, more than four in five working enrollees (83.5%) reported that Medicaid made it easier to work, and 60% of unemployed enrollees reported that Medicaid made it easier to look for work; Michigan’s survey found that 69% of working enrollees said Medicaid helped them do a better job and 55% of out-of-work enrollees said it helped their job search.[38] As discussed in more detail below, it is access to affordable coverage—preventive care, prescription drugs, and regular specialist visits—that enables people to stay healthy and productive.
4. Medicaid Work Requirements Deter and Reduce Coverage; Coverage Loss Seriously Harms Health
The central objective of the Medicaid Act is to provide medical assistance to people who cannot afford it.[39] As written, the IFR adopts policies that will predictably and substantially reduce coverage, cutting against that objective.
For example, after January 1, 2028, the IFR demands that applicants or beneficiaries provide documentation to demonstrate compliance or that they meet an exception or exclusion, except where such documentation is "not reasonably available."[40] That demand cuts against Medicaid's longstanding practice of permitting states to accept self-attestation for nearly every eligibility factor, particularly for people whose eligibility for Medicaid is determined using Modified Adjusted Gross Income.[41] For individuals who should be excluded as medically frail, the burden grows. CMS grafts an entirely new prong onto the exclusion criteria set by Congress, requiring these individuals to demonstrate their condition "significantly impairs" their ability to comply.[42] To make matters worse, after January 1, 2028, they may self-attest to that condition only once for the entire duration of their enrollment.[43] Every time thereafter, they must undertake the onerous work of assembling proof—tracking down medical records, or securing completed forms from clinicians and other providers. This task is required of them yearly, if not more.[44] While the IFR suggests that robust ex parte verification will be possible, that is not the case. No state system is designed to evaluate this new criterion, and building one will be both difficult and expensive.[45] This problem is compounded by CMS’s decision to limit claims data states may use to determine the medically frail exclusion to only 12 months.[46]
Concerningly, CMS has offered no meaningful consideration of the effect of coverage loss on this population generally, or on individuals considered “medically frail” specifically, even though the rule’s own design will strip coverage from eligible people.
The magnitude of the anticipated loss is not speculative. The CBO estimates that the work requirement alone as written in statute will increase the number of uninsured people by roughly 5.3 million in 2034, with the more frequent 6-month redetermination period requirement adding several hundred thousand more people will become uninsured.[47] CBO’s estimate is necessarily an under-estimate of coverage loss, given that the IFR imposes additional requirements on beneficiaries not included in the statute. CBO attributes much of estimated coverage loss not to ineligibility but to the added procedural steps that will be “difficult for states to administer and for enrollees to navigate.”[48] More recent studies found that coverage loss could be far greater—with 7 million individuals losing coverage by 2028 and an additional 3 million lost due to the new 6-month redetermination requirement.[49] Even children will be unable to escape the consequences of these requirements and resulting coverage loss.[50]
The real-world record of Medicaid work requirement programs confirms these projections. In Georgia’s work requirements program, enrollment reached only a small fraction of projections, and among applicants found otherwise eligible, more than 28% were not enrolled for failure to meet the work requirement.[51] In Arkansas, roughly 23% of enrollees subject to the requirement—18,164 people—lost coverage by the end of 2018, prompting the Medicaid and CHIP Payment and Access Commission (MACPAC) to urge a “pause” in implementation.[52] In New Hampshire, roughly two-thirds of those required to report—nearly 17,000 people—did not report sufficient hours and were at risk of losing coverage; in Michigan, roughly 80,000 beneficiaries (one-third of the target population) were similarly at risk.[53] Markedly, coverage loss falls hardest on the people Congress repeatedly stated would not be impacted: adults with chronic conditions and disabilities.[54] In previous work requirement experiments, these individuals were disproportionately likely to lose coverage despite purported exemptions and safeguards.[55]
In 2021, after reviewing the evidence, CMS withdrew Arkansas’s work requirement authority, concluding it did not promote the objectives of the Medicaid program and instead risked significant coverage loss without offsetting benefits.[56] HHS’s own ASPE review conducted in 2021 reached the same conclusion, finding “strong evidence linking health insurance coverage to positive health and economic outcomes” and warning that policies leading to loss of Medicaid coverage will reduce access to care and produce adverse health effects.[57]
Thus, CMS’s choices simply do not align with the evidence. As administrative burdens grow, including repeated verification checks and added paperwork requirements, so does the likelihood that individuals will lose coverage, oftentimes erroneously.[58] This was a lesson concretely learned in the unwinding of the Medicaid continuous enrollment provision. Of the roughly 25 million people disenrolled during redetermination, most lost coverage for procedural reasons—incomplete submissions or unawareness that any submission was required—and in most states procedural terminations accounted for more than 70 percent of all disenrollments.[59] In the IFR, CMS gave little consideration to these consequences while simultaneously acknowledging that “beneficiary awareness, clarity of requirements, and the accessibility of reporting mechanisms, as well as overall administrative complexity, can influence participation and compliance.”[60] But it is precisely these administrative concerns that result in widespread coverage loss.[61]
Coverage loss, in turn, generates cascading harm. It leads people to forgo necessary care and increases financial distress. Medicaid coverage, by contrast, nearly eliminates catastrophic out-of-pocket medical expenditures.[62] Most seriously, gaps in Medicaid coverage are associated with negative health outcomes, including premature mortality.[63]
5. Conclusion
The evidence is clear. Medicaid work requirements do not increase employment; the jobs available to this population do not deliver the health benefits CMS posits; work requirements cause substantial coverage loss; and coverage loss unequivocally harms health. CMS’s premise that the requirement will “empower” beneficiaries and improve their health is without support.
We ask CMS to draft an IFR consistent with the evidence. Where the IFR compounds administrative burden, it will strip coverage from more eligible people. This sits contrary to the objectives of the Medicaid Act and unjustified by any demonstrated health benefit.
We have included numerous citations to supporting research, including direct links to the research. We direct CMS to each of the materials we have cited and have made available through active links, and we request that the full text of each of the studies and articles cited, along with the full text of our comment, be considered part of the formal administrative record for purposes of the Administrative Procedure Act. If CMS is not planning to consider these materials part of the record as we have requested here, please notify us and provide us an opportunity to submit copies of the studies and articles into the record.
[1] Centers for Medicare & Medicaid Services, CMS-2454-IFC/RIN 0938-AV98, Medicaid Program; Community Engagement Requirement for Certain Individuals (June 3, 2026), https://www.federalregister.gov/documents/2026/06/03/2026-11094/medicaid-program-community-engagement-requirement-for-certain-individuals.
[2] 91 Fed. Reg. 33349–50.
[3] 91 Fed. Reg. 33348–49; see also id. at 33372 (same “potential to empower” language). CMS also invokes an “epidemic” of loneliness, asserting that “lacking social connection is as harmful as smoking 15 cigarettes per day.” Id. at 33348–49.
[4] 91 Fed. Reg. 33350.
[5] Danielle Berman et al., Off. of the Assistant Sec’y for Plan. & Evaluation, U.S. Dep’t of Health & Hum. Servs., Medicaid Work Requirements Incentivize Employment and Are Estimated to Reduce Poverty (2026), https://aspe.hhs.gov/reports/medicaid-work-requirements-should-incentivize-employment-reduce-poverty.
[6] Jason B. Cook and Chloe N. East, Evidence from Quasi-Randomly Assigned SNAP Caseworkers (June 2023; revised May 2025), https://www.nber.org/papers/w31307.
[7] Lauren Bauer & Chloe N. East, The Hamilton Project, A Primer on SNAP Work Requirements (2023), https://www.brookings.edu/wp-content/uploads/2023/10/20231004_THP_SNAPWorkRequirements.pdf.
[8] Katherine Richard & Lea Bart, Univ. of Mich. Population Studies Ctr., Penalties in the Safety Net: Effects of Work Requirement Enforcement on Program Participation and Labor Supply (2026), https://krzrich.github.io/website/Richard_Bart_PenaltiesSafetyNet.pdf.
[9] LaDonna Pavetti, Ctr. on Budget & Pol’y Priorities, Work Requirements Don’t Cut Poverty, Evidence Shows (2016), https://www.cbpp.org/research/test-work-requirements-dont-cut-poverty-evidence-shows. The evidence further shows that employment increases among those subject to work requirements were modest and faded over time; stable employment provide the exception rather than the norm; and most recipients with significant barriers to employment never found work even after participating in work programs that were successful for others.
[10] Tazra Mitchell & LaDonna Pavetti, Ctr. on Budget & Pol’y Priorities, Life After TANF in Kansas: For Most, Unsteady Work and Earnings Below Half the Poverty Line (2018), https://www.cbpp.org/research/life-after-tanf-in-kansas-for-most-unsteady-work-and-earnings-below-half-the-poverty-line (finding that the vast majority of participants were employed before and after leaving TANF, with work being just as common at each point in time).
[11] Sandra K. Danziger et al., From Welfare to a Work-Based Safety Net: An Incomplete Transition, 35 J. POL’Y ANALYSIS & MGMT. 231, 234 (2016), https://onlinelibrary.wiley.com/doi/abs/10.1002/pam.21880; Admin. for Child.& Fams., Dep’t of Health & Hum. Servs., Characteristics and Financial Circumstances of TANF Recipients, Fiscal Year 2013, Table 43, https://acf.gov/sites/default/files/documents/ofa/tanf_characteristics_fy2013.pdf.
[12] MaryBeth Musumeci & Julia Zur, Kaiser Fam. Found., Medicaid Enrollees and Work Requirements: Lessons From the TANF Experience (2017), https://www.kff.org/medicaid/issue-brief/medicaid-enrollees-and-work-requirements-lessons-from-the-tanf-experience/.
[13] See Benjamin D. Sommers et al., Medicaid Work Requirements: Results from the First Year in Arkansas, 381 New Eng. J. Med. 1073 (2019), https://www.nejm.org/doi/full/10.1056/NEJMsr1901772 [hereinafter, “Sommers, Results from the First Year in Arkansas”].
Anuj Gangopadhyaya & Michael Karpman, The Impact of Arkansas Medicaid Work Requirements on Coverage and Employment: Estimating Effects Using National Survey Data, Health Servs. Rsch. e14624 (April 2025), https://pubmed.ncbi.nlm.nih.gov/40205643/ (finding an increase in the uninsurance rate and no effect on employment, hours worked, or employer-sponsored coverage).
[14] See Sommers Results from the First Year in Arkansas.
[15] Benjamin D. Sommers et al., Consequences of Work Requirements in Arkansas: Two-Year Impacts on Coverage, Employment, and Affordability of Care, 39 Health Affs. 1522 (2020), https://pmc.ncbi.nlm.nih.gov/articles/PMC7497731/ .
[16] Richard G. Frank & Sherry Glied, ASPE’s Analysis of Medicaid Work Requirements: Argument by Assumption, Health Affairs Forefront (June 12, 2026), https://www.healthaffairs.org/content/forefront/aspe-s-analysis-medicaid-work-requirements-argument-assumption].
[17] Letter from Phillip L. Swagel, Dir., Cong. Budget Off., to Frank Pallone Jr., Ranking Member, H. Comm. on Energy & Com. (April 26, 2023), https://www.cbo.gov/system/files/2023-04/59109-Pallone.pdf.
[18] Chole East & Adrianna McIntyre, The Trump Administration’s Dubious Case for Work Requirements), Can We Still Govern? (June 9, 2026), https://donmoynihan.substack.com/p/the-trump-administrations-dubious?r=slfke&utm_medium=ios&triedRedirect=true.
[19] Id.
[20] Id.
[21] See Gordon Waddell & A. Kim Burton, Is Work Good For Your Health & Well-Being? 34-36 (2006), https://assets.publishing.service.gov.uk/media/5a7c41a540f0b62dffde0df7/hwwb-is-work-good-for-you.pdf (acknowledging that “[g]ood health is not tied only to whether [an individual] work[s]” but to the nature and conditions of the work); Larisa Antonisse & Rachel Garfield, KFF, The Relationship Between Work and Health: Findings from a Literature Review (2018), https://www.kff.org/medicaid/issue-brief/the-relationship-between-work-and-health-findings-from-a-literature-review/ (explaining that job quality mediates the effect of work on health).
[22] See Kristin F. Butcher & Diane Whitmore Schanzenbach, Most Workers in Low-Wage Labor Market Work Substantial Hours, in Volatile Jobs (2018), https://www.cbpp.org/sites/default/files/atoms/files/7-24-18pov.pdf; Hilary Wething, Econ. Pol’y Inst., Work requirements for safety net programs like SNAP and Medicaid: A punitive solution that solves no real problem 8-11 (2025), https://files.epi.org/uploads/294456.pdf; Lauren Bauer et al., Brookings Inst., Low-income workers experience—by far—the most earnings and work hours instability (2025), https://www.brookings.edu/articles/low-income-workers-experience-by-far-the-most-earnings-and-work-hours-instability/; Michael Karpman et al., Urban Inst., Precarious Work Schedules Could Jeopardize Access to Safety Net Programs Targeted by Work Requirements (2019), https://www.urban.org/research/publication/precarious-work-schedules-could-jeopardize-access-safety-net-programs-targeted-work-requirements; Josh Bivens & Shawn Fremstad, Econ. Pol’y Inst., Why Punitive Work-Hours Tests in SNAP and Medicaid Would Harm Workers and Do Nothing to Raise Employment (2018), https://www.epi.org/publication/why-punitive-work-hours-tests-in-snap-and-medicaid-would-harm-workers-and-do-nothing-to-raise-employment/; Tanya L. Goldman et al., Ctr. for Law & Soc. Pol’y, The Struggles of Low Wage Work (2018), https://www.clasp.org/publications/fact-sheet/struggles-low-wage-work-0/ (83% of part-time workers report unstable schedules).
[23] See 91 Fed. Reg. 33350, n. 20 citing Ryan Gerdes et al., Associations Between Employment and Health Outcomes: A Systematic Review of Reviews, J. Occupational Rehab. (Jan. 6, 2026), https://doi.org/10.1007/s10926-025-10357-5 (“Insecure or low-quality work demonstrated the potential to override identified health benefits of work.”).
[24] Andrea L. Steege et al., Examining Occupational Health & Safety Disparities Using National Data: A Cause for Continuing Concern, 57 Am. J. Ind. Med. 527 (2014), https://pubmed.ncbi.nlm.nih.gov/24436156/;[LA7] A.C. Volkers et al., Health Disparities by Occupation, Modified by Education, 7 BMC Pub. Health 196 (2007), https://doi.org/10.1186/1471-2458-7-196; see also Andrea L. Steege et al., Work as a Key Social Determinant of Health, Nat’l Inst. For Occupational Safety and Health (NIOSH), Science Blog (Feb. 16, 2023), https://www.cdc.gov/niosh/bulletin/2023/sdoh.html.
[25] Douglas Jacobs, The Social Determinants Speak: Medicaid Work Requirements Will Worsen Health, Health Affs. Forefront (Aug. 6, 2018), https://www.healthaffairs.org/content/forefront/social-determinants-speak-medicaid-work-requirements-worsen-health ([LA8] citing C.C. Caruso et al., NIOSH, Overtime and Extended Work Shifts: Recent Findings on Illnesses, Injuries, and Health Behaviors (2004)); HHS, Off. of Disease Prevention & Health Promotion, Social Determinants of Health Literature Summaries: Employment, https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/employment.
[26] 91 Fed. Reg. 33350 (emphasis added); see also Seohyun Kim et al., Prevalence of Chronic Disease and Its Controlled Status According to Income Level, 95 Medicine e5286 (2016), https://pmc.ncbi.nlm.nih.gov/articles/PMC5591148/pdf/medi-95-e5286.pdf (CMS cites this article in the IFR to establish the point that financial stability reduces chronic disease; the article makes clear that for low-income individuals, “accessibility of the health system was rather difficult” and, in fact, where the government provided a basic income, the management of chronic disease could improve.
[27] 91 Fed. Reg. 33350 (“[T]he link between health and work is intrinsic and bi-directional whereby work is associated with healthier outcomes, and better health is associated with increased employment.”).
[28] Statistics Netherlands, People out of Work Feel Less Healthy than Those in Work (Feb. 11, 2020), https://www.cbs.nl/en-gb/news/2020/06/people-out-of-work-feel-less-healthy-than-those-in-work.
[29] See 91 Fed. Reg. 33349, n.13 (citing Raj Chetty et al., The Association Between Income and Life Expectancy in the United States, 315 JAMA 1750 (2016)).
[30] Raj Chetty et al., The Association Between Income and Life Expectancy in the United States, 315 JAMA 1750, 1759 (2016), https://pmc.ncbi.nlm.nih.gov/articles/PMC4866586/.
[31] See Quratulain Zafar et al., Economic Strain and Recovery Trajectories in Mental Health: The Role of Financial Stability in Mental Health Outcomes, 7 Rev. Applied Mgmt. & Soc. Sci. 345 (2024), https://doi.org/10.47067/ramss.v7i4.385.; Nicholas K. Brownell et al., Trends in Income Inequities in Cardiovascular Health Among US Adults, 1988–2018, 17 Circulation: Cardiovascular Quality & Outcomes e010111 (2024), https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.123.010111 (concluding that “[t]he improvement in mean cardiovascular risk in the United States has not been complemented by a reduction in income inequities.”).
[32] Robert Wood Johnson Found., How Does Employment—or Unemployment—Affect Health?; see also Workforce Health and Productivity, HEALTH AFFS. (2017), https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1580 (“Policies and benefits such as paid sick leave and unemployment compensation are associated with improved health outcomes.”)
[33] Kenneth C. Hergenrather et al., Employment as a Social Determinant of Health: A Review of Longitudinal Studies Exploring the Relationship Between Employment Status and Mental Health, 29 Rehab. Rsch., Pol’y, & Educ. 261, 280-81 (2015), https://connect.springerpub.com/content/sgrrrpe/29/3/261 (also finding temporary employment associated with poorer mental health).
[34] See 91 Fed. Reg. 33350, n. 17 citing Wen-Jui Han, How Our Longitudinal Employment Patterns Might Shape Our Health as We Approach Middle Adulthood—US NLSY79 Cohort, 19 PLoS One e0300245 (2024), https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0300245 (“This study’s findings highlight the dual challenges facing workers in vulnerable social positions who have jobs requiring nonstandard work schedules, both of which limit their access to resources that would allow them to achieve decent sleep health and physical and mental health outcomes.
This analysis thus calls attention to the reality of how employment as a social system may generate and perpetuate vulnerabilities and inequalities for particular groups over the life course.”).
[35] Robert Grimm, Jr. et al., Corp. for Nat’l & Cmty. Serv., The Health Benefits of Volunteering: A Review of Recent Research (2007), https://generosityresearch.nd.edu/assets/13045/cncs_health_benefits_of_volunteering.pdf; Peggy A. Thoits & Lyndi N. Hewitt, Volunteer Work and Well-Being, 42 J. Health & Soc. Behav. 115 (2001), https://pubmed.ncbi.nlm.nih.gov/11467248/; Jens Detollenaere et al., Volunteering, income and health, 12 PLOS ONE 1, 9 (2017), https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0173139.
[36] Marcia Gibson et al., Welfare-to-Work Interventions and Their Effects on the Mental and Physical Health of Lone Parents and Their Children, Cochrane Database of Systematic Revs. 2, 3 (2018), https://pmc.ncbi.nlm.nih.gov/articles/PMC5846185/.
[37] Mhairi Campbell et al., Lone Parents, Health, Wellbeing and Welfare to Work: A Systematic Review of Qualitative Studies, 16 BMC Pub. Health 188, 195, 197 (2016), https://link.springer.com/article/10.1186/s12889-016-2880-9.
[38] Ohio Dep’t of Medicaid, 2018 Ohio Medicaid Group VIII Assessment 21-22, https://medicaid.ohio.gov/wps/wcm/connect/gov/2468a404-5b09-4b85-85cd-4473a1ec8758/Group-VIII-Final-Report.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWORKSPACE.Z18_K9I401S01H7F40QBNJU3SO1F56-2468a404-5b09-4b85-85cd-4473a1ec8758-nAUQnlt; Susan Dorr Goold & Jeffrey Kullgren, Univ. of Mich. Inst. for Healthcare Pol’y & Innovation, Report on the 2016 Healthy Michigan Voices Enrollee Survey 5 (2018), https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder3/Folder34/Folder2/Folder134/Folder1/Folder234/2016_Healthy_Michigan_Voices_Enrollee_Survey_-_Report__Appendices_11718_final.pdf?rev=bc578064d5be4318acb39796670af8e3.
[39] 42 U.S.C. § 1396-1; see Gresham v. Azar, 950 F.3d 93, 99 (D.C. Cir. 2020) (“The district court is indisputably correct that the principal objective of Medicaid is providing health care coverage.”); Stewart v. Azar, 366 F. Supp. 3d 125, 138 (D.D.C. 2019).
[40] 42 C.F.R. § 435.557(b)(2)(ii).
[41] See 42 C.F.R. § 435.945.
[42] 42 C.F.R. § 435.554(c)(5)(i).
[43] 42 C.F.R. § 435.557(f)(1)(ii).
[44] 42 C.F.R. § 435.557(f)(1)(iii).
[45] See Complaint ¶¶ 129-138, Massachusetts v. Oz, No. 1:26-cv-12962 (D. Mass., June 29, 2026), https://litigationtracker.law.georgetown.edu/wp-content/uploads/2026/06/Massachusetts-v.-Oz_2026.06.29_COMPLAINT.pdf.
[46] 42 C.F.R. § 435.557(f); see also 91 Fed. Reg. 33405 (“States may not consider information older than 12 months when verifying medical frailty or other special medical needs…”).
[47] Cong. Budget Off., Supplemental Cost Estimate of P.L. 119-21 (Oct. 28, 2025), https://www.cbo.gov/system/files/2025-10/PL-119-21-Medicaid%20_0.pdf [hereinafter, CBO Supp. Est.]; see also, Edwin Park et al., Georgetown Univ. Ctr. for Child. & Fams., New CBO Health Coverage Estimates of Budget Reconciliation Law (Aug. 14, 2025), https://ccf.georgetown.edu/2025/08/14/new-cbo-health-coverage-estimates-of-budget-reconciliation-law/ (the Medicaid work requirement is the single largest driver of coverage loss under the law, increasing the uninsured by 5.3 million in 2034, with more frequent redeterminations adding another 700,000 impacted); Michael Karpman et al., Urb. Inst., Assessing Potential Coverage Losses Among Medicaid Expansion Enrollees Under a Federal Medicaid Work Requirement (Mar. 2025), https://www.urban.org/research/publication/assessing-potential-coverage-losses-among-medicaid-expansion-enrollees-under.
[48] CBO Supp. Est. 6.
[49] See Matthew Buettgens et al., Urb. Inst., Projected Reductions in Medicaid Expansion Enrollment Under OBBBA's Work Requirements and Six-Month Redeterminations: National and State Estimates for 2028 (Mar. 2026), https://www.urban.org/research/publication/projected-reductions-medicaid-expansion-enrollment-under-obbbas-work.
[50] See Andrew D. Racine & Jonathan H. Gruber, Cutting Medicaid for Children—A Bet Against the Future, JAMA (July 13, 2026), https://doi.org/10.1001/jama.2026.12868 (“The recently announced rule restricting exemptions from the work requirements will increase the number of adults likely to lose coverage even further. Children’s coverage will decline as a consequence.”).
[51] Ga. Dep’t of Cmty. Health, Georgia Section 1115 Demonstration Waiver Extension Request 10 (2025); MaryBeth Musumeci et al., Few Georgians Are Enrolled in the State’s Medicaid Work Requirement Program, The Commonwealth Fund Blog (Sept. 11, 2024), https://www.commonwealthfund.org/blog/2024/few-georgians-are-enrolled-states-medicaid-work-requirement-program (Georgia projected 100,000 first-year enrollees but enrolled only a few thousand).
[52] Ark. Dep’t of Hum. Servs., Arkansas Works Program December 2018 Report 10; Letter from Penny Thompson, Chair, MACPAC, to Alex Azar II, Sec’y, HHS (Nov. 8, 2018), https://www.macpac.gov/wp-content/uploads/2018/11/MACPAC-letter-to-HHS-Secretary-Regarding-Work-Requirements-Implementation.pdf.
[53] HHS, ASPE, Off. of Health Pol’y, Medicaid Demonstrations and Impacts on Health Coverage: A Review of the Evidence 3 (2021), https://aspe.hhs.gov/sites/default/files/private/pdf/265161/medicaid-waiver-evidence-review.pdf.
[54] For example, in his opening remarks in the Rules Committee, Chairman Guthrie said “Let me be clear – these work requirements only apply to able-bodied adults without dependents who don’t have a disqualifying condition like a disability or substance use disorder,”, https://energycommerce.house.gov/posts/chairman-guthrie-delivers-opening-statement-at-committee-on-rules-hearing-on-the-one-big-beautiful-bill-act; Senator Grassley stated during floor debate “We have reasonable exemptions for: Veterans with [a] disability rated as total. Individuals who are medically frail or otherwise have special medical needs. Individuals who are blind, have [a] substance abuse disorder, a disabling mental disorder, a physical or intellectual disability that significantly impairs their ability to perform one or more activities of daily living or a serious, complex medical condition.”, https://www.grassley.senate.gov/news/remarks/grassley-supports-common-sense-medicaid-work-requirements-for-able-bodied-adults (June 24, 2025); and Senate Majority Leader Thune issued a press release stating “Republicans’ bill establishes work requirements for able-bodied adults who don’t have dependent children younger than 14 years of age or a disabled individual in their care.” and “The work requirement doesn’t apply to anyone who is disabled, pregnant or caring for a child younger than age 14. Volunteering 20 hours a week or enrolled in school? You can get Medicaid.”, https://www.republicanleader.senate.gov/newsroom/research/republicans-reconciliation-bill-strengthens-medicaid (July 15, 2025). Many additional Members of Congress also explicitly mentioned exemptions for people who are medically frail or have disabilities throughout the debate on OBBBA.
[55] Lucy Chen & Benjamin Sommers, Work Requirements and Medicaid Disenrollment in Arkansas, Kentucky, Louisiana, and Texas, 2018, 110 Am. J. Pub. Health 1208 (2020), https://pubmed.ncbi.nlm.nih.gov/32552024/; MaryBeth Musumeci, KFF, Disability and Technical Issues Were Key Barriers to Meeting Arkansas’ Medicaid Work and Reporting Requirements in 2018 (2019), https://www.kff.org/medicaid/disability-and-technical-issues-were-key-barriers-to-meeting-arkansas-medicaid-work-and-reporting-requirements-in-2018/.
[56] Letter from Elizabeth Richter, Acting Adm’r, CMS, to Dawn Stehle, Ark. Dep’t of Hum. Servs. 4-9 (Mar. 17, 2021), https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ar-works-ca2.pdf.
[57] HHS, ASPE, Off. of Health Pol’y, Medicaid Demonstrations and Impacts on Health Coverage: A Review of the Evidence 6-7 (2021), https://aspe.hhs.gov/sites/default/files/private/pdf/265161/medicaid-waiver-evidence-review.pdf.
[58] Pamela Herd et al., Interventions to Automate Medicaid Renewals Reduce Procedural Denials and Increase Coverage, 44 Health Affs. 1336, 1336 (2025), https://www.healthaffairs.org/doi/10.1377/hlthaff.2025.00316; Leighton Ku et al., The George Washington Univ. Dep’t of Health Policy, Improving Medicaid's Continuity of Coverage and Quality of Care 12–16 (2009), https://hsrc.himmelfarb.gwu.edu/sphhs_policy_facpubs/248/.
[59] Adrianna McIntyre et al., New Medicaid Enrollment Barriers and Lessons from Unwinding, 6 JAMA Health F. e254849, at 1 (2025), https://pubmed.ncbi.nlm.nih.gov/40906465/.
[60] 91 Fed. Reg. 33350.
[61] See, e.g., Ashley M. Fox et al., Administrative Easing: Rule Reduction and Medicaid Enrollment, 80 Pub. Admin. Rev. 104 (2020), https://scholarsarchive.library.albany.edu/cgi/viewcontent.cgi?article=1010&context=rockefeller_pad_scholar;
KFF, Implications of Emerging Waivers on Streamlined Medicaid Enrollment and Renewal Processes (Feb. 28, 2018), https://www.kff.org/affordable-care-act/implications-of-emerging-waivers-on-streamlined-medicaid-enrollment-and-renewal-processes/.
[62] Katherine Baicker et al., The Oregon Experiment-Effects of Medicaid on Clinical Outcomes, 368 New Eng. J. Med. 1713 (2013), https://www.nejm.org/doi/full/10.1056/NEJMsa1212321; “Somers, Consequences of Work Requirements in Arkansas.”
[63] See, e.g., Sarah Miller et al., Nat’l Bureau of Econ. Rsch., Medicaid and Mortality: New Evidence From Linked Survey and Administrative Data, Working Paper 26081 (2019), https://www.nber.org/papers/w26081; Benjamin D. Sommers et al., Mortality and Access to Care among Adults after State Medicaid Expansions, 367 New Eng. J. Med. 1025 (2012), https://www.nejm.org/doi/full/10.1056/NEJMsa1202099; Benjamin D. Sommers et al., Health Insurance Coverage and Health-What the Recent Evidence Tells Us, 377 New Eng. J. Med. 586 (2017), https://pubmed.ncbi.nlm.nih.gov/28636831/; Jacob Goldin et al., Health Insurance and Mortality: Experimental Evidence from Taxpayer Outreach, 136 Q.J. Econ. 1 (2021), https://www.nber.org/papers/w26533.
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