What does it mean to be medically frail?
For the purposes of avoiding new work requirements for government subsidized health care, the Trump administration includes in its definition of medical frailty having cancer, a drug addiction, mental illness, and other documented conditions that make it difficult for people to take care of themselves.
But what should be a straightforward exercise for applicants risks turning into an onerous ordeal that can strip health care from thousands of sick patients in the process, according to health care experts who have reviewed the new federal guidelines for Medicaid work requirements issued by the Centers for Medicare & Medicaid Services in early June.
Not only will people have to receive a qualifying diagnosis, they’ll also have to prove their illness makes them so sick that they can’t work. And health care providers charged with evaluating individuals for exemptions say they haven’t received any guidance to determine who is sick enough.
“You can’t build a house, pass an inspection, and then be told the blueprints were wrong all along,” said Dr. Rishi Wadhera, a Harvard Medical School assistant professor who has conducted studies identifying the populations most at risk of losing their coverage.
The national work requirement, included in President Trump’s One Big Beautiful Bill Act that passed Congress last year, mandates that most Medicaid recipients between the ages of 19 and 64 will have to prove they work, attend school, or volunteer at least 80 hours a month to obtain coverage.
Some work exemptions, such as those for people who are pregnant or caring for children 13 and younger, will be relatively easy to document.
But, proving the extent of someone’s disability is an extraordinarily high bar to meet, experts said. The health of people with chronic, serious conditions can vary day by day. A person who passes a performance test or screening questions one day may not be able to do the same a week later.
And some conditions, such as mental illness, cannot be easily quantified in a way that proves or disproves a person is able to hold down employment, or even volunteer work.
What those specific documentation requirements will look like remains to be seen and will likely vary by state, said Adrianna McIntyre, an assistant professor of health policy and politics at Harvard’s T.H. Chan School of Public Health.
“Whatever additional direction [the Centers for Medicare & Medicaid and Services] gives, I expect states will make different choices in how to operationalize medical frailty, where some states will require more paperwork than others,” McIntyre said.
A Harvard study published in March found that among the millions of Medicaid enrollees nationally at risk of losing Medicaid coverage because they don’t work enough hours, one third reported poor physical health and a third reported poor mental health that could prevent them from meeting the federal work requirements.
“The frailty exemption was the law’s promise that the sickest people would be protected,” said study author Dr. Rishi Wadhera from Harvard. The new federal guidelines, he added, go back on the promise and shift “the burden onto the very people unable to meet that burden of proof.”
The administration’s guidelines note some conditions that could exempt someone from work requirements may worsen or improve over time, so people with a medical frailty exemption are required to document their condition at least every year for as long as they’re on Medicaid.
The requirements will also create significantly more paperwork, for both the state agency MassHealth and the thousands of physicians, nurse practitioners, therapists, and other health care providers, who will soon have to routinely render a judgment on the severity of their patients’ conditions.
State policy leaders have long anticipated the new rules, which federal officials have said are supposed to reduce Medicaid fraud, will create new obstacles for people eligible for the low-income insurance program; one estimate found more than 200,000 MassHealth members could lose coverage. But they were thrown by just how extensive the documentation requirements will be — and how hard it will be to prove exemptions.
State officials already face a time crunch to bring MassHealth policies in line with federal rules by the end of the year. Now those officials, along with health care providers and policy makers, must pivot to contend with the new guidelines.
It will be a new challenge for Massachusetts, which has never required Medicaid recipients to prove they’re working.
Hannah Frigand, a senior director at health advocacy organization Health Care for All, said states are under pressure to make the system easy for Medicaid users to navigate.
“It’s on all of us to help people understand who will be exempt and who needs to take action,” Frigand said. “It’s just that we need to fully understand the mechanics of it in order to make sure we’re giving out the best information.”
A MassHealth spokesperson said in a statement that the program is reviewing the federal requirements.
“Our top priority remains ensuring that as many eligible people as possible maintain coverage and access to care,” the spokesperson said.
The Centers for Medicare & Medicaid Services, which issued the new guidelines for the work rules, did not immediately respond to questions from the Globe.
Massachusetts has promised to use databases and state records to automatically confirm some exemptions from the work requirements. But many MassHealth members who should be eligible for exemptions don’t even show up in those files, including people experiencing homelessness.
The guidelines also say states will have leeway to set their own definitions of medical frailty. But Massachusetts has not yet announced what those conditions would be.
Under the new federal guidelines, Medicaid beneficiaries can self-declare they meet the qualifications for a medical frailty exemption for the program’s first year. Beginning in 2028, however, MassHealth users will have to provide documentation to prove their exemption status.
After the self-attestation window is over, the grunt work of proving medical frailty requirements could fall on the shoulders of already stretched-thin health care providers.
“We don’t do employability assessments. That’s not a regular part of our job,” said Dr. Benjamin Sommers, a Harvard health economist and primary care physician. “It would take a lot of staff hours, and again, we’re not really trained for this.”
Dr. Mohammad Dar, chief medical officer at the Community Care Cooperative, a nonprofit network of clinicians, and former senior medical director at MassHealth, said some patients are already concerned and confused over the work requirements.
Dar also noted the implications of these additional requirements will reach far beyond MassHealth users.
“It’s going to pull bandwidth away from front-line primary care providers and other providers such that they have less ability … to care for everyone in a state where we know we have long wait times to begin with,” Dar said.
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