Researchers at the Urban Institute estimate that between 4.9 million and 10.1 million people could lose Medicaid coverage in 2028 because of new work requirements and more frequent eligibility checks created by last year’s federal tax and spending law. The wide range reflects how much individual states do, or don’t do, to help people keep documenting their eligibility, and several states are already implementing the changes ahead of the federal deadline. For people nearing retirement age who rely on Medicaid or expect to need it before Medicare eligibility begins, the range itself is a warning that a lot depends on decisions their own state has not yet finalized.
Where the 4.9 Million Figure Comes From
The estimate comes from a Robert Wood Johnson Foundation-funded Urban Institute analysis published March 25, 2026, modeling the coverage effects of H.R. 1, the tax and spending law that created new work requirements for Medicaid expansion enrollees and requires states to check their eligibility every six months instead of annually. The researchers modeled high, medium, and low state-mitigation scenarios: under the scenario where states do the most to help people keep their coverage, about 4.9 million people lose Medicaid in 2028; under the scenario where states do the least, the number rises to 10.1 million. Of that total, the researchers attribute between 2 million and 3.1 million losses to more frequent eligibility redeterminations alone, and between 3 million and 7 million to the new work requirements.
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Working People Are Not Exempt in Practice
One of the researchers’ more striking findings is that meeting the work requirement on paper does not guarantee someone keeps their coverage. The Urban Institute projects that between 19 percent and 37 percent of people who already work will nevertheless lose Medicaid, often because they face challenges documenting irregular hours, self-employment income, or seasonal work in the format state systems require. The analysis also found that many people who would qualify for an exemption altogether — because they are a student, a family caregiver, or living with a disability — are still projected to lose coverage, typically because the paperwork proving the exemption does not reach the state in time or in the right form.
States Are Already Moving on Different Timelines
The federal law leaves significant implementation choices to individual states, and some are moving faster than others. Nebraska began enforcing its work requirement on May 1, 2026, and Montana followed on July 1, 2026, according to tracking by health policy researchers, making both states early test cases for how the rules play out in practice. Because the Urban Institute’s 4.9 million to 10.1 million range depends heavily on how much outreach and support each state provides, the experience in early-moving states like Nebraska and Montana may offer the clearest preview yet of which end of that range the rest of the country is likely to land closer to.
The Funding Cut Behind the Coverage Changes
The work requirements are only part of a larger financial shift for Medicaid. According to the Commonwealth Fund’s analysis of state responses to H.R. 1, federal Medicaid spending is set to drop by $900 billion over the next ten years, the largest funding reduction in the program’s history. North Carolina has projected it will lose $40 billion in federal funding over that period, while Minnesota estimates an annual loss of about $200 million. In response, states including Idaho and North Carolina have already announced across-the-board cuts to provider payment rates, and Colorado has suspended a previously scheduled Medicaid rate increase, moves that can make it harder for enrollees who keep their coverage to find a provider who will still accept it.
States Are Also Paying to Administer the New Rules
Verifying work status and running eligibility checks twice a year instead of once is not free for the states that have to build the systems to do it. The Commonwealth Fund’s analysis cites prior state experience with work-requirement systems showing administrative costs ranging from $6 million in New Hampshire to $271 million in Kentucky, and notes that Arizona’s Medicaid program has already requested $71.4 million from its governor specifically to implement H.R. 1’s new requirements. New Mexico’s governor called a special legislative session to address lost state revenue and ensure the state’s Medicaid agency has the resources to implement the law, since most state budgets for the current fiscal year were adopted before H.R. 1 passed and did not anticipate the added administrative cost.
Benefits Already Being Trimmed
Beyond eligibility and provider rates, some states are responding to the funding cuts by paring back optional benefits that are not required under federal Medicaid rules, including dental coverage and home- and community-based services that many older and disabled enrollees rely on. Colorado has announced cuts to some dental spending, and North Carolina is anticipating further service eliminations and staff reductions as its fiscal year continues. The Commonwealth Fund’s researchers note that only a handful of states have finalized their responses so far, with more decisions expected as 2026 state legislative sessions and year-end budget negotiations play out.
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The SNAP & Medicaid Renewal Organizer includes a 13-page organizer, 51 state packs and a renewal document checklist.
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This article was written with the assistance of AI and reviewed for accuracy before publication.
David M. Keller is a finance writer based in Columbus, Ohio, covering personal finance and consumer-focused economic topics. He earned his degree in journalism from Ohio University and began his career reporting on local business and economic trends for a regional media outlet. Since then, he has contributed to a variety of online publications, focusing on clear, practical coverage of topics such as cost of living, debt, and everyday financial decision-making.
