The complicated regulations may lead eligible patients to lose their insurance and force doctors to do more work with lower payment, ultimately jeopardizing patient care and health outcomes, according to a new Perspective in the New England Journal of Medicine.
Beginning in January 2027, millions of low-income adults with Medicaid coverage will be required to document at least 80 hours of employment, job training, volunteering, or education each month to maintain their insurance coverage. Since these new "community engagement" requirements passed in the One Big Beautiful Bill Act ( H.R.1 ) in July 2025, health and policy experts have sounded the alarm on the significant administrative burdens these requirements will place on Medicaid recipients and states alike, which could result in up to 10 million people losing their insurance coverage.
These new conditions for Medicaid eligibility may also pose grave challenges for physicians and the practice of medicine as a whole, according to a new Perspective by Boston University School of Public Health (BUSPH) researchers in the New England Journal of Medicine.
Physicians will be expected to adhere to new rules for determining and documenting Medicaid enrollees who are exempt or excluded from these requirements, including people who are "medically frail" and deemed to have certain limitations impacting their ability to work.
These new rules will create an unprecedented task for healthcare providers marked by extensive paperwork, pressure on states to not be too generous with exemptions, and likely worsening health for patients losing coverage and unable to access care, write Nicole Huberfeld , Edward R. Utley Professor of Health Law at BUSPH and Boston University School of Law, and Dr. Paul Shafer , associate professor of health law, policy & management and codirector of the Medicaid Policy Lab at BUSPH.
"Clinicians have not faced this kind of demand, which asks them to determine a patient has significant medical needs and that their medical frailty is a barrier to meeting the conditions of eligibility for insurance," says Prof. Huberfeld. "They are likely to face pressure from states to document extra carefully, when they are already squeezed for time. It's a no-win situation for providers and for patients."
Once the new regulations take effect nationwide next year, adult Medicaid expansion enrollees without an exemption will have to meet the required community engagement activities for one to three months prior to the month they apply for coverage, depending on where they live. Physicians will be operating under magnified pressure from the Centers for Medicare and Medicaid Services (CMS) to clamp down on Medicaid fraud, with CMS threatening "corrective action" against states in which the agency believes physicians are granting exclusions to patients too frequently.
"Although the threats are directed at states, states will rely on physicians' documentation to prove that they shouldn't face corrective action, and if a state loses federal funding, health care organizations and clinicians may not get paid," the authors write in the Perspective.
Clinicians also face an expected decline in Medicaid payments as states are forced to account for lost revenue due to the nearly $1 trillion in projected federal funding cuts to Medicaid under H.R.1. This funding loss could place rural hospitals and safety-net hospitals—many of which are already vulnerable—at financial risk due to a steep rise in uncompensated operating costs, the authors note. Rural hospitals serve more than 25 percent of the US population, and more than 100 of these hospitals have closed over the last decade, leaving millions of Americans without access to emergency services, testing, inpatient care, and primary care.
"Medicaid already struggles with getting physicians to participate, adding more paperwork and potentially reducing reimbursements while losing patients may only make the problem worse," says Dr. Shafer. "This would impact everyone enrolled in Medicaid, not just those subject to the new work requirements."
Recent research by Dr. Shafer also found that nearly 20 percent of eligible adults living in Medicaid expansion states may be unable to meet the minimum work hours that will go into effect on January 1, with women, unmarried people, White individuals, and those with limited education at higher risk of losing their Medicaid coverage due to this noncompliance with these new requirements. Past data consistently indicate that Medicaid work requirements don't actually achieve the intended goal of increasing employment; instead, these requirements are costly to states, confusing to enrollees, and an arduous process for both groups, often leading enrollees to become discouraged and abandon the time-consuming applications.
"Congress's desire to increase employment and self-sufficiency may result in the opposite, removing the only source of health insurance coverage for low-income people and, paradoxically, making it harder for them to maintain employment," Prof. Huberfeld and Dr. Shafer write. "Neither legislators nor CMS appear to have considered the predictable effects on health care providers, but H.R.1 will soon once again demonstrate that law is a determinant of health for patients and physicians. And as the new regulations place doctors and patients in direct conflict, patient care will certainly suffer."
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About Boston University School of Public Health
Founded in 1976, Boston University School of Public Health is one of the top ten ranked schools of public health in the world. It offers master's- and doctoral-level education in public health. The faculty in six departments conduct policy-changing public health research around the world, with the mission of improving the health of populations—especially the disadvantaged, underserved, and vulnerable—locally and globally.
