The Trump administration’s appetite for cruelty and its wanton disregard for wasting taxpayer funds has shown itself again – this time in its proposed regulations for implementing the One Big Beautiful Bill Act’s (OBBBA) Medicaid eligibility requirements. But as new details emerge, there are some possible ways that states could protect eligible populations from losing health care.

The proposed regulations, which were officially released on June 3, require many individuals with serious illnesses or medically complex situations to prove they are unable to meet work requirements. This upends months of guidance to states from an agency of the Department of Health and Human Services that has informed the tens of millions of dollars they have already spent building information systems to collect and confirm individuals’ eligibility for Medicaid in time for the January 1, 2027 start date of the new regulations.

Based on advice from administration officials, state health departments hired staff, upgraded technology and developed systems to manage eligibility to determine which individuals are working and which will have work requirements waived based on their medical condition. But those efforts will now be superseded by the nearly 400-page long proposed regulations, and information systems will have to be reconfigured to conform to the changes. It should be noted that there is something deeply ironic about an administration that professes an aversion to bureaucracy releasing a 400-page proposal that gives states guidance on how to oversee new bureaucratic systems.

Defining “Medically Frail”

The Trump administration’s work requirements for disabled, near-poor individuals to qualify for Medicaid go well beyond what the OBBBA requires. Many seriously ill individuals or those with medically complex situations will be required to prove they are too disabled to work – a Catch-22 proposition for a population that may be too physically compromised to comply. In a 387-page advance document, the proposed rule explicitly removes from the category of medically frail individuals those undergoing treatment for cancer or who have been diagnosed with end stage renal disease. They, along with many others with debilitating conditions, will need to show that they are, indeed, medically frail and unable to work in order to have the work requirement waived.

The Affordable Care Act expanded Medicaid’s coverage of low-income people by raising the income threshold for eligibility to 138 percent of the poverty line ($21,597 for an individual in 2025). Many people earning more than the poverty line but less than this amount work in industries where employers do not offer health insurance benefits and the cost of private health insurance is too high for workers to afford. About 67.8 million people are covered by Medicaid today, and more than 20 million of these are in the Medicaid expansion group.

The changes to Medicaid eligibility in the OBBBA affect this expansion group, including a requirement for states to condition Medicaid eligibility for adults in that group on meeting work requirements starting next January. The proposed regulations will govern who must meet the requirement of 80 hours a month of work or volunteer activities for able-bodied people covered by Medicaid. Work requirements in the OBBBA were waived for medically frail individuals. But the proposed regulations go beyond the legislation and require disabled individuals to prove they are too incapacitated to work.

In 2027, the new regulations allow a medically frail individual who is unable to document their inability to meet the work requirement to provide a statement attesting to their medical frailty under penalty of perjury. In 2028, an individual who cannot produce such documentation will be able to attest to this once under penalty of perjury, but will be required to produce documentation six months later at the next regularly scheduled renewal. 

Disabled people are disproportionately represented among those who use Medicaid. Among working-age adults, 28 percent of Medicaid enrollees report at least one type of disability, compared to just 7.7 percent of those who do not use Medicaid. Navigating alternative programs like Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) can take years of appeals and paperwork, requiring both money and expertise. Even among disabled Medicaid enrollees, only about 35 percent also receive SSI, and many don’t have another formal recognition of their disability. Medicaid remains one of the only dependable ways that disabled people have been able to access the medical care and equipment they need to survive.

The work requirements are not actually intended to weed out able-bodied people on Medicaid who do not work. Currently, 64 percent of Medicaid recipients are employed full or part-time. Of the remaining 36 percent, 8 percent are unemployed and 28 percent are students, pregnant, parents of young children, or disabled and qualify for an exemption from the work requirements. Rather, the rules around work requirements and the related red tape have been designed to be difficult for Medicaid recipients to navigate, and to do so twice a year instead of annually as is now the rule. The expectation is that millions of people will fail to navigate the red tape — and will be removed from the Medicaid rolls for administrative reasons even though they work or meet the conditions to have work requirements waived.

That is how the Trump Administration expects to save $900 billion to $1 trillion in federal spending over 10 years to pay for its tax cuts for the wealthy.

Can States Fix the OBBBA Mess?

But it does not have to work out this way. States may have a tool at their disposal that can thwart this plan, save inner city and rural hospitals, and fill a crater-sized hole in budgets of states committed to access to healthcare for its poor or disabled people.

Medicaid is a mandatory program established by Congress in 1965 as an amendment to the Social Security Act. It is mandatory in two ways. Any individual who meets their state’s eligibility requirements and applies for Medicaid must receive this health insurance. And when a state spends money on its Medicaid program, the federal government must reimburse the state for the federal share of the program’s costs. That’s why Congress cannot simply cut the government’s spending on Medicaid. It can only manipulate the eligibility criteria and hope many Medicaid beneficiaries will have difficulty meeting them and will drop off.

And that suggests a possible path for states that do not want to see poor people in need of health insurance thrown off Medicaid, vital hospitals forced to close, and state budgets under pressure. States that want to maintain health coverage for near-poor and disabled residents can mitigate some of the worst effects of the new regulations by hiring navigators, much as they did in the early years of the Affordable Care Act, to help people manage the reporting requirements and remain enrolled in Medicaid. 

Navigators have done much more than simply enroll eligible individuals in health insurance programs. They also conduct public education and outreach activities, especially in underserved communities where people’s situations can change during the year due to events beyond their control such as job loss. In addition, they assist with assembling material to document work verification or incapacity for work. 

States can train navigators to understand the system they have put in place to confirm Medicaid beneficiaries work and waiver status and to deal with the reporting requirements on behalf of the poor and disabled individuals that depend on the program. 

This will be a win-win solution — except for those in the Trump administration and Congress that want to finance tax cuts for the wealthy by denying health care to the poor. States that welcome the proposed regulations as an opportunity to save money by reducing their Medicaid rolls are failing to account for the deterioration in their public health system, the increases in uncompensated care costs, and the hospital failures in communities with few health resources.

Navigators could also be used to help SNAP recipients remain enrolled in that program and prevent poor children from going hungry – another ruse to finance tax cuts for the wealthiest by depriving the poorest of necessities.

Health care and food are vital necessities, and no one should be denied access to them. States can make sure that doesn’t happen.