An analysis by the Urban Institute projects that up to 2.3 million young adults could lose Medicaid coverage by 2028 under the work requirements of the One Big Beautiful Bill Act. Although nearly 90% of affected young adults currently meet the requirements or qualify for exemptions, administrative barriers and limited state tracking data are expected to drive significant disenrollment. Meanwhile, federal and state crackdowns on Medicaid fraud are causing unintended disruptions, with autism therapy clinics reporting severe service reductions due to aggressive rate cuts and new paperwork rules.
Young adult Medicaid work requirements
- ▪The new Medicaid work requirements and eligibility checks were enacted under the One Big Beautiful Bill Act in 2025 and are scheduled to take effect on January 1, 2027.
- ▪An analysis published by the Urban Institute on September 14, 2026, projected that between 1.1 million and 2.3 million young adults aged 19 to 24 could lose Medicaid coverage by 2028 due to new work requirements.
- ▪Under the One Big Beautiful Bill Act, expanded Medicaid enrollees must work, volunteer, or participate in education for at least 80 hours per month, or be a half-time student, unless they qualify for an exemption.
- ▪The Urban Institute report found that 88% of young adults aged 19 to 24 covered under expanded Medicaid already meet the work requirements or qualify for an exemption.
State implementation administrative barriers
- ▪More than two dozen states are suing the Trump administration to make it easier for Medicaid beneficiaries to prove they are exempt from the upcoming work requirements.
- ▪Nebraska, Montana, Iowa, and Arkansas are rolling out Medicaid work requirements in advance of the official federal deadline of January 1, 2027.
- ▪Young adults face a higher risk of losing Medicaid coverage because they move more frequently and participate in gig work, which are difficult for state administrative systems to track.
Autism therapy fraud crackdown impact
- ▪Nebraska cut Medicaid reimbursement rates nearly in half for basic life skills autism therapy in August 2025, while New York, Indiana, and Colorado implemented cuts ranging from 5% to 25% in 2026.
- ▪Autism therapy providers in Nebraska, Colorado, and New York report that new state-level Medicaid rules, rate cuts, and paperwork requirements are reducing access to care for children.
- ▪The Trump administration's crackdown on Medicaid fraud, led by CMS Administrator Mehmet Oz, has targeted states with high rates of improper billing for autism therapy.
Medicaid enrollment projection losses
- ▪The Urban Institute projects that overall Medicaid enrollment could drop by 5 million to 10 million people due to the administrative barriers introduced by the One Big Beautiful Bill Act.
- ▪Depending on state implementation, expanded Medicaid enrollment among young adults could drop by 22% in a high-mitigation scenario and up to 48% in a low-mitigation scenario.
Medical frailty exemption guidance
- ▪The American Medical Association stated on September 11, 2026, that while data-driven exemptions are helpful, many individuals will still require manual reviews because administrative data often fails to capture functional limitations.
- ▪The Centers for Medicare and Medicaid Services published guidance on September 8, 2026, confirming that states can use existing health data to automatically identify medically frail individuals for work exemptions.
Debatable claims
- ▪The One Big Beautiful Bill Act's Medicaid work requirements should be repealed
- ▪The Trump administration's Medicaid fraud crackdown on autism therapy unfairly restricts access to care
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