Most Medicaid enrollees facing the work rule already qualify. The early losses came from paperwork.

Update, October 15: We rechecked this story against current sources. Ohio Medicaid’s own count of the expansion group is 774,342, not the 700,000 first used here. The Congressional Budget Office numbers below describe the version the House passed, and the medical-frailty exemption must be reverified every 12 months, not every six months as first written. Pennsylvania released its exemptions and began mailing notices in September. Nebraska, which went first in enforcing the rule, has released early results, and Ohio’s own enrollment breakdown is added before the Sources.

Start with the two people this argument keeps invoking. One is heavily disabled and cannot work 80 hours. The other is working, drawing a real paycheck, and still carries the card. Each side keeps its favorite in view and ignores everyone else.

What the 2025 law changed

For years, this was optional. If a state wanted to make Medicaid recipients work for their coverage, it had to go to Washington and ask for special permission, and most never bothered. Ohio did get that permission back in 2019, then never turned the rule on before the Biden administration cancelled it in 2021. So it stayed an argument. The big 2025 budget law ended the choice. Work, or what the rule calls “community engagement,” is now baked into federal law as a condition of keeping Medicaid for adults covered through the expansion, in every state that expanded, on a federal timetable that some states beat and others can ask to stretch. Ohio and Pennsylvania do not get to decide whether to do this anymore. They only get to decide how.

The expansion group

So who does this reach? Not everyone on Medicaid, which is the first thing the shouting gets wrong. It reaches one specific slice, the one Ohio files under the bland label “Group VIII,” the expansion group. When the Affordable Care Act let states widen Medicaid back in the 2010s, Ohio and Pennsylvania both said yes, and saying yes opened the program to a set of adults who had never qualified before: working-age people, roughly 19 to 64, earning under about $22,025 a year for a single person, not sick enough to be on the old disability track and not old enough for Medicare. Before the expansion, a childless adult could be flat broke and still get turned away at the door. Those are the people the expansion covers, and they are the only ones this rule touches. Children, seniors, and people on the disability track are not in it.

What the states still control is how hard the rule bites: how strictly the hours are checked, who counts as too sick to work, whether optional hardship carve-outs are used, and how fast notices go out. Ohio Medicaid counted 774,342 enrollees in that expansion group as of July 2025; Pennsylvania’s estimates run from about 750,000 to about 800,000. Parents and caretakers of a child 13 or under, or of a disabled family member, are meant to be exempt, and people already meeting the work rules for food stamps or cash assistance can carry those across.

Counting the 80 hours

The qualifying activity, from CMS and Ohio’s own FAQ:

• 80 hours a month of work, community service, or a work program, or
• school at least half time, or
• a combination that adds up to 80 hours, or
• monthly earnings of at least 80 times the federal minimum wage, which works out to $580 in 2026.

Ohio’s minimum wage runs higher than the federal floor, so a person paid Ohio’s minimum clears the income test in fewer hours; Signal Cleveland walked the state’s math out to about 53. So a low-wage worker can meet the test in fewer than 80 hours.

One state over: Pennsylvania

Pennsylvania runs the same expansion program under the same federal floor, with roughly 750,000 to 800,000 adults in its expansion group, close to Ohio’s count. The January 1, 2027 deadline is identical. What differs is how far along each state is on the parts it controls. Ohio has published its Group VIII enrollment count and said it will not ask for the long delay. Pennsylvania has published its start date, its exemption list and a schedule that accepts a signed statement in place of documents (self-attestation) in 2027 and asks for documents from 2028. It is still working out how it will identify medically frail enrollees, and no delay request has been reported.

Both states have loss estimates. The Pennsylvania Health Law Project estimates about 310,000 Pennsylvanians could lose coverage, though that figure combines the new work requirement with the law’s move to twice-a-year renewals, not the hours rule alone. An Urban Institute model of an earlier and narrower federal design, covering expansion adults ages 19 to 55, put Ohio and Pennsylvania among 11 states that would each lose more than 100,000 expansion enrollees.

How many lose the card

Nobody knows how many will be removed; it depends on how well each state runs verification. An earlier Congressional Budget Office analysis of the House-passed bill put roughly 18.5 million adults under the rule each year, with about 5.2 million losing federal Medicaid and 4.8 million more uninsured by 2034. For the law as enacted, the health research group KFF reports that CBO estimates the work requirement leaves about 5.3 million more people uninsured in 2034. Every number here is a projection, and they differ mostly in how many eligible people they assume the paperwork will drop by mistake.

Arkansas ran a Medicaid work requirement at scale in 2018, the closest real-world test so far. In the first seven months, more than 18,000 people lost coverage, one in four of those subject to the rule, and a study by Benjamin Sommers and colleagues in Health Affairs found no significant change in employment. The Center on Budget and Policy Priorities cites national estimates that about nine in ten adults who could face such a rule already work or meet an exemption, and the Arkansas losses came largely from confusing notices and reporting barriers. People were not cut off for turning down shifts. They lost coverage because they never heard about the rule, or could not clear the reporting. In a survey of Arkansans ages 30 to 49 who lost Medicaid or marketplace coverage in 2018, 26 percent were uninsured in late 2019, and half reported serious problems paying medical debt.

Disabled adults and the exemption form

Take the person who genuinely cannot work: a body or mind that will not deliver 80 reliable hours of anything. If they already get federal disability checks, what is called SSI, and their Medicaid comes through that door, this rule is not aimed at them. If they landed in the expansion group because they never won a disability determination, they now have to prove frailty or lose the card, and proving it takes a signed form, a doctor’s note and a state willing to accept them. The Health Policy Institute of Ohio reports that Ohio is not adopting the optional hardship exemptions, including one for high-unemployment counties. A RAND estimate cited there puts Ohio’s loss near 172,600 people over ten years and about $12.4 billion in Medicaid funding. Treat it as an estimate.

For someone with a genuine disability who is not on SSI, the exemption is where it gets hard. The statute exempts the “medically frail,” which covers disabling physical and mental conditions. But the rule leans on state data-matching to confirm exemptions automatically where it can, and medical frailty is one of the categories a database usually cannot confirm on its own. So the burden falls back on the person, who must refile every 12 months or sooner, with a cutoff notice waiting if a letter goes unanswered. Those likeliest to lose coverage are sick or disabled adults without a formal determination, and caregivers who assumed the exemption was automatic.

Now consider the worker who is still on Ohio Medicaid. Working while covered is allowed, because eligibility follows income, and a low-wage full-time job can sit under the line. Ohio also runs a separate door, the Medicaid Buy-In for Workers with Disabilities (MBIWD), which lets workers with disabilities ages 16 to 64 earn more and keep coverage by paying a premium. Two different cases get lumped together. Sometimes the person is poor and insured, which is exactly the design. Sometimes a file is stale and an income change should have closed the case already, which is a verification failure. When verification is run clumsily, the red tape hits sick and tired people, as it did in Arkansas.

Each side leaves something out. DeWine’s case does not say what happens to eligible people who miss a notice; in Arkansas, the program cut off 18,000 people within seven months. Arkoosh’s does not account for the 8 in 100 expansion adults the chart shows as neither working nor exempt.

Both pictures are real, and neither one describes 774,342 Ohioans or the Pennsylvanians next door. Below, Nebraska’s results so far show at least 1,090 people denied or dropped, by Georgetown’s count, and Ohio’s own records show 22.3 percent of its expansion group still needs an individual assessment.

Nebraska’s first four months

Nebraska began enforcing the work requirement on May 1, 2026, the first state to do so, and started disenrolling current enrollees this summer. KFF analyzed the figures Nebraska presented to its Medicaid Advisory Committee on September 17, which cover applications processed from May through August and renewals processed from July to mid-August.

Nebraska processed 9,614 applications and denied 4,434 for reasons unrelated to work, such as income above the limit. Of 4,089 applicants covered by the rule, 46 percent met a qualifying activity, 39 percent qualified for an exemption (Nebraska calls it an exclusion), and 2 percent (92 people) received a short-term hardship exception. The remaining 14 percent, or 557 people, were denied. Of those denials, 84 percent came from not answering a request for information and 16 percent from a finding of noncompliance.

Of 7,280 renewals under the rule, 57 percent held an exemption, 34 percent showed a qualifying activity, 127 people (2 percent) got a short-term exception for hardship, and 533 people, or 7 percent, lost coverage. Of those, 92 percent did not respond to verification requests and 8 percent were found noncompliant. The 557 denials and 533 terminations add up to 1,090 decisions, which the Georgetown University Center for Children and Families counts as people losing coverage or being denied. Applications and renewals are separate counts, so the figure may not be 1,090 different people, and the state has not confirmed a total.

Correction, October 24, 2026: The headline said most people who lose Medicaid to the rule are already working. The evidence here shows that most enrollees subject to the rule already work or qualify for an exemption, and that most early losses in Nebraska came from unanswered paperwork; it does not show the work status of the people who lost coverage. The headline now says what the evidence supports. We also narrowed “every state at once” and noted that the 1,090 figure counts decisions, not necessarily unique people.

Nebraska’s Department of Health and Human Services says the changes aim to raise workforce participation and curb Medicaid misuse, as Drew Gonshorowski, director of its Division of Medicaid and Long-Term Care, told KETV in April, and spokesperson Collin Spilinek said in June the agency had no plans to pause. DHHS chief executive Steve Corsi, quoted by Nebraska Public Media, put the number who had come off Medicaid at between 600 and 900, against the 200 the agency expected in the first round. CMS Administrator Dr. Mehmet Oz praised Nebraska on October 10 for going first and said its results give him confidence about the January 1 national start.

Others read the same figures differently. Sarah Maresh of Nebraska Appleseed, a legal advocacy group, has urged a pause, and the group estimated that up to 40,000 Nebraskans could eventually lose coverage; Corsi disputed that, saying about 25,000 of roughly 70,000 expansion adults could be affected. Joan Alker of the Georgetown center wrote that the losses so far are mostly procedural, since 92 percent of renewing enrollees who lost coverage were denied for not providing requested information, and that the rules hit applicants harder than current enrollees. KFF adds that it is unclear whether those who did not respond were ineligible, unaware of the requests or unable to document their status. CMS has told Nebraska to change how it verifies medical frailty, and the state must respond in October.

Georgia has run a work requirement under a waiver since 2023 and offers another data point. Human Rights Watch reports that Georgia recorded 17,638 denials between October 2024 and September 2025, about half of them for failing to meet or verify the requirement.

Ohio’s own count of who already qualifies

Ohio Medicaid’s own data, presented in a November 2025 webinar slide deck, listed 774,342 people in Group VIII, the expansion group, from July 2025 eligibility records. The state’s records already showed 601,882 of them, or 77.7 percent, meeting the federal rule: 329,397 working (42.5 percent), 142,662 medically frail or disabled (18.4 percent), 74,498 eligible on another Medicaid basis (9.6 percent), 23,382 in another qualifying activity (3.0 percent), 16,653 parents of children 13 or younger (2.2 percent), 14,940 who were pregnant, incarcerated or former foster youth (1.9 percent), and 350 in a small age-based category. The other 172,460 people, or 22.3 percent, need an individual assessment.

That gives a state-level check on the national chart earlier in this story. KFF puts 64 of every 100 expansion adults at work, while Ohio’s records match 42.5 of every 100 to work and about 35 more to other exemptions. The deck does not explain the difference. It was written when Ohio planned to start under its own waiver in June 2026, with a 20-hour weekly test and an age cutoff of 55; the federal rule, which starts January 1, 2027, replaced those terms.

The slides also lay out how Ohio will check. It looks first at state data such as wages, then at documents from enrollees it could not verify, then sends two checklists of acceptable proof, and the verification request that follows counts as the notice of noncompliance. The enrollee then has 30 days to show compliance before coverage ends or an application is denied.

Notices and renewals in Ohio and Pennsylvania

Pennsylvania’s September letters went to almost 700,000 enrollees, with automated calls and texts starting in mid-September, according to the Department of Human Services’ September 10 announcement. Work requirements and six-month renewals start January 1, 2027, but current enrollees report at their next renewal in or after February 2027, so coverage does not change on January 1. For expansion-group adults aged 19 to 64, retroactive coverage can be backdated only one month before the application (it was three), and two months for everyone else. Anyone asked for more information gets 30 days to answer.

Ohio is also mailing notices, Signal Cleveland reported on September 23. An Ohio Medicaid spokesperson told the outlet the department does not plan to request the delay. The state plans to use about 1,900 medical codes to flag medically frail enrollees, a list that is not yet public, and Tara Britton of the Center for Community Solutions says Ohio will not accept self-attestation of medical frailty next year, for now.

The federal rule sets the outer limits. CMS requires states to reverify medical frailty at least every 12 months. States may accept self-attestation through 2027 when reliable data is missing, but from 2028 only once per enrollment period, and the condition must “significantly impair” the person’s ability to comply, according to KFF.

Still unconfirmed

Nebraska has not explained why 4,434 applicants were denied for non-work reasons, a category Georgetown’s Alker calls a key question, or whether the people who ignored its letters were ineligible. Alker expects the frailty change CMS ordered to raise losses. Ohio has not said how many of its 172,460 unassessed enrollees will qualify. No state has published a full year of results, so every national projection in this story remains an estimate.

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