New Medicaid Work Rules Likely To Hit Middle-Aged Adults Hard
•February 11, 2026
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Why It Matters
The policy threatens health security for a vulnerable segment of the population and could shift long‑term care costs onto Medicare, undermining overall system sustainability.
Key Takeaways
- •20 million low‑income adults face new Medicaid work mandates
- •Women 50‑64 most likely to lose coverage
- •Exemptions for caregivers are narrow and unclear
- •Coverage loss may increase future Medicare costs
Pulse Analysis
The Republican‑led budget law introduces Medicaid work requirements that demand able‑bodied adults log 80 hours of qualifying activity each month. While the intent is to promote self‑sufficiency and protect program finances, the rule will apply to roughly 20 million low‑income Americans across 42 states, excluding the non‑expansion states that opted out of the Affordable Care Act’s Medicaid expansion. Early estimates from the Congressional Budget Office suggest the mandate could strip coverage from at least five million people within a decade, making it the largest driver of Medicaid attrition in the legislation.
Middle‑aged adults, particularly women between 50 and 64, are the group most vulnerable to these mandates. Many serve as primary caregivers for children, aging parents, or spouses with disabilities, limiting their ability to meet the 80‑hour threshold. Chronic conditions such as arthritis, hypertension, and mental health issues further reduce work capacity, yet Medicaid remains their primary source of medical care. The narrow exemptions for caregivers and disabled individuals lack precise definitions, creating administrative hurdles that could force many to fall through the cracks, jeopardizing both physical health and financial stability.
Beyond the immediate human toll, the work requirements may generate higher downstream costs for the broader health system. Loss of Medicaid coverage can lead to untreated conditions, resulting in more acute episodes that require expensive emergency care. As these adults age into Medicare eligibility, a sicker cohort could inflate Medicare spending, counteracting any short‑term savings envisioned by the rule. Policymakers and advocates therefore argue for clearer exemption criteria and robust support mechanisms to avoid a costly shift of burden from Medicaid to Medicare and to preserve health equity for the nation’s most vulnerable workers.
New Medicaid Work Rules Likely To Hit Middle-Aged Adults Hard
Lori Kelley’s deteriorating vision has made it hard for her to find steady work.
The 59-year-old, who lives in Harrisburg, North Carolina, closed her nonprofit circus arts school last year because she could no longer see well enough to complete paperwork. She then worked making dough at a pizza shop for a bit. Currently, she sorts recyclable materials, including cans and bottles, at a local concert venue. It is her main source of income ― but the work isn’t year-round.
“This place knows me, and this place loves me,” Kelley said of her employer. “I don’t have to explain to this place why I can’t read.”
Kelley, who lives in a camper, survives on less than $10,000 a year. She says that’s possible, in part, because of her Medicaid health coverage, which pays for arthritis and anxiety medications and has enabled doctor visits to manage high blood pressure.
But she worries about losing that coverage next year, when rules take effect requiring millions of people like Kelley to work, volunteer, attend school, or perform other qualifying activities for at least 80 hours a month.
“I’m scared right now,” she said.
Before the coverage changes were signed into law, Republican lawmakers suggested that young, unemployed men were taking advantage of the government health insurance program that provides coverage to millions of low-income or disabled people. Medicaid is not intended for “29-year-old males sitting on their couches playing video games,” House Speaker Mike Johnson told CNN.
But, in reality, adults ages 50 to 64, particularly women, are likely to be hit hard by the new rules, said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes KFF Health News. For Kelley and others, the work requirements will create barriers to keeping their coverage, Tolbert said. Many could lose Medicaid as a result, putting their physical and financial health at risk.
Starting next January, some 20 million low-income Americans in 42 states and Washington, D.C., will need to meet the activity requirements to gain or keep Medicaid health coverage.
Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming didn’t expand their Medicaid programs to cover additional low-income adults under the Affordable Care Act, so they won’t have to implement the work rules.
The nonpartisan Congressional Budget Office predicts the work rules will result in at least 5 million fewer people with Medicaid coverage over the next decade. Work rules are the largest driver of coverage losses in the GOP budget law, which slashes nearly $1 trillion to offset the costs of tax breaks that mainly benefit the rich and increase border security, critics say.
“We’re talking about saving money at the expense of people’s lives,” said Jane Tavares, a gerontology researcher at the University of Massachusetts Boston. “The work requirement is just a tool to do that.”
Department of Health and Human Services spokesperson Andrew Nixon said requiring “able-bodied adults” to work ensures Medicaid’s “long-term sustainability” while safeguarding it for the vulnerable. Exempt are people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship, Nixon told KFF Health News.
Medicaid expansion has provided a lifeline for middle-aged adults who otherwise would lack insurance, according to Georgetown University researchers. Medicaid covers 1 in 5 Americans ages 50 to 64, giving them access to health coverage before they qualify for Medicare at age 65.
Among women on Medicaid, those ages 50 through 64 are more likely to face challenges keeping their coverage than their younger female peers and are likely to have a greater need for health care services, Tolbert said.
These middle-aged women are less likely to be working the required number of hours because many serve as family caregivers or have illnesses that limit their ability to work, Tolbert said.
Tavares and other researchers found that just 8% of the total Medicaid population is considered “able-bodied” and not working. This group consists largely of women who are very poor and have left the workforce to become caretakers. Among this group, 1 in 4 are 50 or older.
“They are not healthy young adults just hanging out,” the researchers stated.
Plus, making it harder for people to maintain Medicaid coverage “may actually undermine their ability to work” because their health problems go untreated, Tolbert said. Regardless, if this group loses coverage, their chronic health conditions will still need to be managed, she said.
Adults often start wrestling with health issues before they’re eligible for Medicare.
If older adults don’t have the means to pay to address health issues before age 65, they’ll ultimately be sicker when they qualify for Medicare, costing the program more money, health policy researchers said.
Many adults in their 50s or early 60s are no longer working because they’re full-time caregivers for children or older family members, said caregiver advocates, who refer to people in the group as “the sandwich generation.”
The GOP budget law does allow some caregivers to be exempted from the Medicaid work rules, but the carve-outs are “very narrow,” said Nicole Jorwic, chief program officer for the group Caring Across Generations.
She worries that people who should qualify for an exemption will fall through the cracks.
“You’re going to see family caregivers getting sicker, continuing to forgo their own care, and then you're going to see more and more families in crisis situations,” Jorwic said.
Paula Wallace, 63, of Chidester, Arkansas, said she worked most of her adult life and now spends her days helping her husband manage his advanced cirrhosis.
After years of being uninsured, she recently gained coverage through her state’s Medicaid expansion, which means she’ll have to comply with the new work requirements to keep it. But she’s having a hard time seeing how that will be possible.
“With me being his only caregiver, I can’t go out and work away from home,” she said.
Wallace’s husband receives Social Security Disability Insurance, she said, and the law says she should be exempt from the work rules as a full-time caregiver for someone with a disability.
But federal officials have yet to issue specific guidance on how to define that exemption. And experience from Arkansas and Georgia ― the only states to have run Medicaid work programs ― shows that many enrollees struggle to navigate complicated benefits systems.
“I’m very concerned,” Wallace said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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