A medical condition should not become a reason to lose access to care. But that is precisely what is at stake in a legal fight over new federal Medicaid work requirements.
The One Big Beautiful Bill Act of 2025 added work requirements for certain Medicaid beneficiaries starting in 2027. Congress also recognized that people with serious medical conditions, legally known as “medically frail,” should not lose Medicaid coverage simply because they cannot work.
However, this important exemption for a vulnerable population is at risk. In issuing guidance for state implementation of Medicaid work requirements, the Centers for Medicare & Medicaid Services (CMS) added a significant hurdle to qualify for the exemption that Congress never wrote. It mandates that an adult enrollee must not only have a qualifying diagnosis but also demonstrate that the condition “significantly impairs” their ability to meet the 80-hour per month work or community engagement requirement.
The AMA and our partners in medicine believe CMS has unlawfully narrowed protections Congress established for medically frail patients and created barriers that could put their coverage at risk.
Rule will harm access to care
The AMA, joined by eight other medical associations, filed an amicus brief (PDF) this week in a federal lawsuit brought in Maryland challenging the CMS guidance. We also filed a friend-of-the-court brief in July in a similar suit brought in Massachusetts. We believe the CMS rule goes beyond what Congress intended and that many patients, otherwise eligible, will be unable to meet the new requirement.
A patient’s condition does not always fit neatly into a government definition or a particular length of time. Symptoms can fluctuate. Treatment can be debilitating. A person may be able to work at one point but be unable to manage the demands of work at another.
Millions of Americans will lose coverage. When people lose coverage, we all pay the price. Preventive screenings are missed. Treatable illnesses become life-threatening. Chronic conditions go unmanaged. And patients who might have recovered with timely treatment end up in emergency rooms, sicker and facing far more costly care.
Medicaid expansion under the Affordable Care Act helped 20 million people gain coverage. Evidence shows that Medicaid coverage is linked to earlier treatment and better outcomes for people with serious conditions, including cancer, heart disease and substance use disorders.
Diverting physicians from care delivery
CMS also is adding to the paperwork burden on physicians and care teams. Under the rule, clinicians may be asked to determine whether patients’ medical condition significantly impairs their ability to comply with work requirements. Physicians are trained to diagnose and treat illness, not to make vocational assessments under unclear standards. Time spent on eligibility paperwork is time taken away from patient care.
There is another risk: patients may hesitate to speak openly about pain, fatigue, mental health symptoms or substance use if they fear those conversations could affect their coverage. A strong patient-physician relationship depends on trust. Patients should not have to weigh that trust against the risk of losing access to treatment.
Mounting paperwork demands
The rule also restricts when states can accept a patient’s own attestation of medical frailty. Starting in 2028, patients could face repeated demands for documentation of their condition. Those additional steps can become barriers for people already managing serious illness.
CMS should stop putting barriers between medically frail patients and the care they need. Physicians should spend their time treating patients, not proving that those patients deserve to keep their Medicaid coverage.
Congress recognized that medically frail patients need protection. That protection must mean more than words on a page. It must mean patients can maintain their coverage, continue their treatment and get the care they need, when they need it.
