A quiet countdown is underway in American healthcare. On January 1, 2027, millions of Medicaid enrollees will be required to document 80 hours per month of work, job training, education, or community service or risk losing their health coverage. Yet according to a new survey from The Health Management Academy, more than half of those enrollees have no idea it’s coming.
The survey was conducted in April 2026 among 1,974 adults currently enrolled in Medicaid. It reveals a striking awareness gap ahead of what the Congressional Budget Office projects will be the largest reduction in federal Medicaid spending in the program’s history.
The findings raise urgent questions not just about policy communications, but about what happens to patients, hospitals and health systems when coverage is disrupted at scale.
More Than Half Haven’t Heard About Medicaid Work Requirements
When survey asked if they knew that completing 80 hours per month of qualifying activity would become a condition of Medicaid eligibility in January 2027, 55% of enrollees were completely unaware. Another 27% said they had heard something but were unsure of the details. Only 17% said they were aware of the requirement.
Furthermore, 85% of respondents did not know eligibility checks would shift from annually to every six months. All of these changes were included in Trump’s One Big Beautiful Bill Act signed into law on July 4, 2025.
The results demonstrate a major communication issue that state Medicaid agencies will need to surmount in an accelerated timeframe. States are required to begin enrollee outreach no later than June 30, 2026. Initial outreach needs to be complete by August 31, 2026. The Department of Health and Human Services’ interim final rule on implementation is due in June 2026. In most states, the message hasn’t even been sent.
Here’s the issue: prior experience suggests that communication is a major issue in this population. When Arkansas implemented Medicaid work requirements in 2018, a Harvard survey found that more than 70% of affected residents remained unsure whether the policy was in place, even after the state sent nearly 600,000 letters, made 230,000 phone calls, and published hundreds of social media posts.
Medicaid Work Requirements Will Cause People To Lose Coverage
Arkansas’s work requirement experiment resulted in approximately 18,000 people losing coverage in its first year before it was halted by federal courts. Most lost coverage because of paperwork barriers, not because they failed to work.
The survey when on to asked enrollees what they would do if they lost their Medicaid coverage. Among the 49% of respondents reporting a chronic health condition requiring ongoing medication or treatment, roughly 62% said they would ration or stretch their existing medication and 58% said they would stop filling at least one prescription. About 55% said they would skip specialist appointments.
When asked which medications they would stop taking first, mental health drugs topped the list at 25%, followed by blood pressure and cholesterol medications at 22%, and diabetes medications at 17%.
From a clinical perspective, abrupt discontinuation of regular medication can carry risks. For example, stopping antidepressants or anxiety medication can lead to severe worsening of the condition or potentially dangerous withdrawals. Interruptions in antihypertensives and statins can raise heart risks over time, and in some cases lead to hypertensive emergencies. Stopping diabetes medications can trigger hyperglycemic crises like diabetic ketoacidosis which can require ER visits and sometimes hospitalization.
ERs Are Expected To Be The Safety Net For Coverage Loss
When asked how they would seek care if they lost coverage, 37% of the survey’s respondents said they would wait until a health issue became urgent. Then they would go to the ER. Another 28% said they would use the ER for routine care they currently receive from a regular doctor. Among enrollees with chronic conditions, nearly two-thirds said they would turn to the ER in at least one of these ways.
This is a familiar pattern for emergency physicians. ERs have always served as the health system’s backstop for patients with no other options. The Federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires that ER doctors evaluate and stabilize anyone who walks through the door, regardless of ability to pay.
What the survey predicts is a surge in uncompensated ER visits at precisely the moment many of the hospitals that are expected to absorb those visits face severe financial strain.
An April 2026 analysis identified 446 hospitals across 44 states at high risk of closing or reducing services because of Medicaid funding cuts. These facilities derive at least 20% of their revenue from Medicaid and related programs and have been operating at a loss.
Medicaid Work Requirements Will Exacerbate Racial Disparities
A subgroup analysis in the survey sharpen concern around health equity. Black enrollees reported the highest rate of unawareness of work requirements at 62%, compared to 56% among White enrollees and 54% among Hispanic enrollees. They were also the most likely to say they could not travel farther if their nearest hospital closed.
Transportation access will compound the risks. About 62% of all respondents said they do not drive themselves to medical appointments, relying on family members, public transit, or other means. Among urban enrollees, 73% do not drive to care and 45% said they could not travel farther if a nearby hospital reduced services. In rural areas, the gaps are different in character but no less serious: greater distances to care and fewer transportation options.
Older enrollees are also disproportionately vulnerable. Those 65 and older were less aware of the coming changes than younger adults and more likely to say they would ration medication—47% of that age group compared to 35% of those ages 25 to 34.
Here’s What Health Systems Can Do About Coming Medicaid Work Requirements
Operational implications for health systems require action before enrollment disruption begins next year. Community health workers, patient navigators and care management teams should be proactively identifying high-risk Medicaid patients with chronic medical issues. The focus should be on those with conditions where medication disruption could lead to acute medical issues like mental health and diabetes. Outreach regarding the requirements and implications of the new law should begin immediately.
Systems with significant Medicaid payer mix also will face a direct revenue impact: fewer covered visits, more uncompensated ER care and higher acuity when patients present after months of deferred treatment. Importantly, health systems should be running scenarios now for volume and revenue impact.
Ultimately, HMA’s survey findings make one thing clear: when state outreach begins this summer, it will reach a population starting from near zero. Most enrollees have not heard the message. Many will be surprised to learn that their coverage is contingent on documentation that could prove difficult and administratively burdensome to provide.
According to the Congressional Budget Office, 5.3 million Medicaid beneficiaries are expected to lose coverage by 2034 as the new work requirements are launched.
The survey data present an early warning. The question is how state agencies, health systems and advocacy organizations engage individuals at risk to ensure that individuals – in particular, the most vulnerable ones – don’t lose their coverage.
