On July 30, 2026, U.S. District Judge Richard Stearns of Massachusetts declined to block a new Medicaid work-requirement rule, denying a preliminary injunction sought by more than two dozen Democratic-led states. The ruling was procedural, not a decision on the merits, which is expected before the rule takes effect, but it leaves the rule in place for now.
The rule, issued by the Centers for Medicare and Medicaid Services to carry out the work requirement in the Trump-signed budget law, requires many Medicaid enrollees to document 80 hours a month of work or qualifying activity. What drew attention is how it treats the seriously ill: a terminal diagnosis such as cancer, HIV/AIDS, or Parkinson's does not, on its own, qualify someone for an exemption. The enrollee must additionally show that the condition “significantly impairs” their ability to meet the requirement, a standard advocates warn will strip coverage from people too sick to navigate the paperwork.
The framing that the administration “argues even terminally ill patients shouldn't be exempt” is the outlets' characterization of the rule's practical effect; the government's position in court was to urge the judge to reject the states' challenge, which he did. States must begin the work requirements by January 2027, and must tell enrollees by the end of August 2026 how the changes will affect them. The requirement that seriously ill enrollees also show their condition “significantly impairs” their ability to comply begins January 1, 2028 (see Trump Signs Bill Cutting Over $1 Trillion From Health Programs as CBO Estimates 10 Million More Uninsured).
Update (September 16, 2026): a study published August 28 in JAMA Health Forum by researchers at Boston University and the University of South Carolina found that 19.8 percent of employed adults likely eligible for Medicaid through expansion are at risk of losing coverage because their work hours are too low (13.6 percent) or too variable (7.6 percent) to reliably meet the 80-hour monthly threshold. “These findings suggest that millions of enrollees may lose Medicaid coverage without access to affordable alternatives,” the authors wrote. The study gives a share, not a headcount.
Correction (September 16, 2026): an earlier version of this entry said the work requirements take effect January 1, 2028. States must implement them by January 2027; the 2028 date applies to the added “significantly impairs” showing for seriously ill enrollees.
Update (October 30, 2026): On October 29, Judge Stearns gave the 25 states and the District of Columbia a partial victory, the AP reported. He ruled that the CMS guidance released in June, which requires people in the medically frail categories to show their conditions also “significantly impair” their ability to comply, went beyond what Congress passed in 2025 and is “thus contrary to law,” Politico reported. “There is an inherent public interest in ensuring that the government follows the law,” he wrote, adding that “enforcement of an unlawful definition of 'medically frail' may lead to the disenrollment of otherwise eligible vulnerable individuals relying on Medicaid coverage for continuity of care.”
The court also ordered states to wait at least six months after the work rules take effect before cancelling the coverage of anyone claiming a medical exemption, Politico reported. Stearns upheld the requirement that states reject proof of medical frailty more than 12 months old and a policy allowing states to accept only one self-attestation per continuous enrollment period, finding “the government provided a non-frivolous rationale for adopting each provision.” The ruling does not strike down the work requirements, which begin January 1. CMS declined to comment on whether it will appeal, Politico reported. A separate challenge by medical groups and the city of Columbus, Ohio, is pending in Maryland.
Update (October 31, 2026): With the January 1 deadline two months away, some states are warning they will not be ready, Politico reported. Louisiana still does not know how to verify school enrollment, Missouri has no automatic way to verify medical exemptions, and Colorado must request paperwork from 175,000 people it could not check automatically. Hannah Katch, a former CMS senior adviser under Biden now working with several states: “I don't know of a single state that has tested and confirmed it can protect coverage for eligible people with Medicaid.” CMS did not answer whether it will give states more time.