A federal judge ruled Thursday that the Trump administration unlawfully narrowed who counts as “medically frail” under the new Medicaid work requirements, blocking a rule that would have exempted only people whose illness keeps them from meeting those requirements.
U.S. District Judge Richard Stearns in Boston sided with 25 states and the District of Columbia, led by California, Massachusetts and New Jersey. The work requirements take effect Jan. 1, 2027, and apply to adults 19 to 64 in the Medicaid expansion: 80 hours a month of work, community service or at least half-time school, or they lose coverage.
For Black communities the stakes run through the exemption. Medicaid fills the gaps in employer coverage that people of color face more often, according to KFF’s analysis of 2022 coverage data, so a rule that makes it harder for chronically ill adults to qualify for an exemption lands first on the people who depend on the program.
The Centers for Medicare and Medicaid Services (CMS) issued guidance in June to carry out the work requirement written into last year’s reconciliation law. It said a person’s physical, mental or other behavioral health condition must “significantly impair the individual’s ability to comply with the community engagement requirement” before the exemption applies. The states said that test would force sick people to clear extra hurdles to keep coverage.
Stearns agreed that the definition was unlawful. “Because enforcement of an unlawful definition of ‘medically frail’ may lead to the disenrollment of otherwise eligible vulnerable individuals relying on Medicaid coverage for continuity of care, the States (and public) face potential for great hardship in the absence of an injunction,” he wrote. He gave states a six-month stay while they change their verification systems.
It is a reversal of fortune for the states. On July 29, Stearns denied their request to block parts of the same rule, finding they had not shown they would suffer irreparable harm before the case was decided. That ruling did not settle the merits and was issued without prejudice.
The last time a state tried this, the result was measurable. Arkansas imposed Medicaid work requirements in 2018, and about 18,000 people lost coverage before a federal judge ended the program in 2019.
CMS did not immediately respond to a request for comment on the ruling. The case continues in Boston, and states must be ready to enforce the work requirements, with whatever definition of frailty survives, by Jan. 1.
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