More than 200,000 Massachusetts residents could lose MassHealth coverage in 2028 because of new requirements under President Trump’s signature One Big Beautiful Bill, according to a new report.
Depending on the level of state intervention, the law’s upcoming work requirements and more frequent Medicaid redeterminations could lead to 99,000 to 202,000 people in Massachusetts being booted from the state’s Medicaid program, which insures low-income individuals, according to the report by the Robert Wood Johnson Foundation and Urban Institute.
Massachusetts stands to lose a larger proportion of its Medicaid rolls than any other state because of work requirements and eligibility checks, according to the report. Even the most conservative estimates project the state to see a 33 percent drop in expansion enrollment. That’s in spite of a longstanding state commitment to expanding access to MassHealth and discounted insurance options through the HealthConnector, Robert Wood Johnson Foundation senior policy officer Katherine Hempstead said.
“It’s a little bit paradoxical, because it reflects the fact that Massachusetts has a pretty generous safety net already,” Hempstead said.
It’s already easier for parents in Massachusetts to be eligible for MassHealth than in other states, Hempstead said. The population in Massachusetts that is able to get Medicaid through an expansion of the insurance program, aimed at opening the insurance to more low-income adults, includes more non-parents who are less likely to qualify for an exemption.
Additionally, Massachusetts has a higher minimum wage than other states, meaning that many workers already earn more than is allowed to qualify for MassHealth.
“The Medicaid expansion population then has fewer employed people,“ so they’re less likely to be able to stay on Medicaid under the new requirements, Hempstead said.
Beginning Jan. 1, 2027, MassHealth members ages 19 to 64 who qualify for the insurance through the Affordable Care Act, or Obamacare, expansion will have to prove that they work or volunteer for at least 80 hours per month, unless they meet certain exemptions, such as caregiving for children under 13, being pregnant, or being medically frail. MassHealth members will also have to have their eligibility rechecked every six months.
The changes could prove financially disastrous for Massachusetts hospitals who rely on Medicaid, especially those that care for a high proportion of low-income patients. If patients are kicked off of the insurance and unable to find other coverage, hospitals foot the bill for emergency care. Already, UMass Memorial Health has slashed some services.
MassHealth’s estimate for people who will ultimately lose coverage because of these requirements — about 175,000 Massachusetts residents — falls toward the higher range projected by the report.
“We are really committed to implementing these changes in the most thoughtful way that minimizes impact to the members and coverage, while, of course, maintaining that federal compliance,” said Elizabeth LaMontagne, MassHealth chief operating officer.
In their projections, report authors considered each state’s population who currently qualify for Medicaid under the Obamacare expansion and estimated how many could prove they are working and how many meet the standards for an exemption. The Robert Wood Johnson Foundation is a New Jersey health equity philanthropy and the Urban Institute is a nonprofit research organization focused on social and economic policy in Washington.
Massachusetts residents between the ages of 50 and 64 are particularly vulnerable, Hempstead said, because they may have health problems that don’t qualify as a disability but that limit their ability to work. Medicare, the federal health insurance program for older adults, doesn’t kick in until age 65.
The work requirement exemptions include medical frailty, but the federal government hasn’t defined what specific conditions will be considered exempt. The Centers for Medicare & Medicaid Services are supposed to give written guidance on the rollout of the work requirements in June, LaMontagne said.
In the meantime, MassHealth and community partners are ramping up efforts to limit the number of people who are kicked out of the program for procedural reasons. That means using income, education, and claims data to automatically determine whether some individuals are already in compliance with the new requirements.
But some work, such as gig-economy jobs like driving for Uber or Lyft, can be harder for the state to track.
“We can’t get everybody automatically confirmed. Some people will have to take action, whether that’s submitting proof of income or submitting documentation,” LaMontagne said.
The state will return to a playbook it used during the unwinding of pandemic-era continuous Medicaid coverage, partnering with community organizations to educate at-risk groups about what they need to do to maintain their health insurance.
In a statement, Ashley Blackburn, interim executive director for health advocacy organization Health Care for All, said the group is working closely with MassHealth on outreach strategies “to ensure federal work reporting requirements and additional administrative barriers have the least possible negative impact on Massachusetts residents as possible.”
For now, the state is working to balance awareness with limiting unnecessary concern for MassHealth users.
“We’re trying to really focus first on adults ages 19 to 64 and then highlighting some of the other exemptions that carve out people,” LaMontagne said. “If you have a child who’s under 14, or if you have a disability, then you are not impacted by these.”
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