When Republicans passed Trump's budget bill last summer, they added work requirements to Medicaid: low-income adults covered under the program's expansion would have to prove they work, go to school or volunteer, or lose their health coverage. The rules start January 1, 2027.
The law carved out an exemption. People who are "medically frail" — seriously ill or disabled — don't have to meet the work rules at all.
Then Trump's Department of Health and Human Services wrote the rule that decides who counts as medically frail. And according to two lawsuits, it shrank the exemption Congress wrote.
What the rule does
On June 3, HHS and the Centers for Medicare & Medicaid Services published a rule on Medicaid's work requirements. It lists who qualifies as medically frail: people who are blind or disabled, people with a disability that interferes with daily living, people with substance use disorders or disabling mental disorders, and people with "serious or complex" medical conditions.
But there's a catch. Even people in those groups still have to prove their condition hinders their ability to work, Stateline reported. The law's exemption became a new round of paperwork.
When Maryland sued in June, its attorney general's office said that despite "months of working with states," CMS surprised states with a rule that "adopted a new interpretation of key terms like 'medically frail' and makes it harder for medically vulnerable individuals to be excused from the work requirements."
Who gets hurt
The lawsuit filed Friday names the kinds of patients at risk: people with cancer, diabetes, HIV, substance use disorders and other behavioral health conditions. The five Medicaid enrollees suing — from Kentucky, Illinois, Indiana, Missouri and North Carolina — live with autism, obsessive-compulsive disorder, bipolar disorder, severe vision loss, HIV and narcolepsy.
The groups suing alongside them are not fringe organizations. They include the American College of Physicians and the American Academy of Pediatrics, plus Doctors for America, the Society for Adolescent Health and Medicine, the New Hampshire Medical Society and the city of Columbus, Ohio.
Their announcement says the rule puts sick people through "new reporting and verification requirements, even though Congress categorically excluded medically frail people from the requirements."
"As physicians, we are trained to diagnose and treat our patients' medical conditions, not to conduct assessments about a given patient's ability to work," said Dr. Jan K. Carney, president of the American College of Physicians.
The lawsuit points out who pays when people lose coverage: when cities and localities provide services for residents who lose their Medicaid, "they do so without compensation." Columbus's city attorney, Zach Klein, said the rule "needlessly puts people's lives at risk and inevitably drives up the cost of care for everyone."
The numbers from one state
Maryland ran the math after the rule came out. Its own analysis suggests that about 150,000 people — at least 45% of the adults covered by Maryland's Medicaid expansion — will be dropped at some point once the rule takes effect. The state warned that may be an undercount, because the rule "now requires 'medically frail' individuals to demonstrate significant impairment to their ability to work." Running it will also raise the state's administrative costs by an estimated 20%.
That's why 24 attorneys general and two governors — from Arizona and Michigan to Kentucky and Pennsylvania — sued in June. Maryland's Attorney General Anthony Brown said the rule strips people's coverage "not because they fail to qualify, but because the administration has rewritten the rules to exclude them."
Paperwork, not work
Republicans sold work requirements as a way to push people into jobs. But most Medicaid adults already work or are in school, Stateline noted. When Iowa's Ashley Hinson defended the idea — "If you're going to take a taxpayer benefit, you should be working" — the numbers showed the people she was talking about were already doing it.
What work requirements reliably do is knock eligible people off coverage through paperwork. The states' lawsuit, as Maryland's attorney general describes it, accuses HHS of ignoring "substantial evidence that work reporting requirements cause eligible individuals to lose healthcare coverage because of administrative barriers rather than a failure to work." A rule that makes the sickest people prove their sickness adds one more form to lose coverage over.
The requirements didn't come out of nowhere, either. Florida Republican Aaron Bean wrote the bill twice before it became part of the budget law.
In summary
Trump's budget bill exempted "medically frail" people from Medicaid's new work requirements. A June 3 rule from Trump's health department narrowed that exemption, requiring even people who are disabled or seriously ill to prove their condition hinders their ability to work. Maryland estimates about 150,000 of its residents will lose coverage at some point under the rule. Twenty-four attorneys general and two governors sued in June; doctors' groups, five patients and the city of Columbus sued on Friday.
Source
Medical groups, patients sue Trump administration over Medicaid work requirements — Nada Hassanein, Stateline, September 21, 2026.
