25 states and the District of Columbia sued the Trump administration on Monday over new Medicaid work requirements guidance, saying the federal rules will block eligible people from getting care and pile fresh paperwork onto a safety net already built to ration access. The lawsuit targets an interim final rule released earlier this month by the Centers for Medicare and Medicaid Services, and the states say the agency went beyond the text of the law passed last summer that set the changes in motion.
Who Gets Crushed
The people at the bottom of this arrangement are the ones who will have to prove they deserve care. Starting Jan. 1, expansion enrollees age 19 to 64 will have to show that they work or do community service at least 80 hours a month or are in school at least half the time. The law includes exceptions for those considered medically frail or in addiction treatment programs, among others, but the states say the Trump administration’s new guidance narrows those exceptions and creates harmful coverage barriers.
The plaintiffs say the Republican administration’s interpretation of the statute will create chaos in states that have been rushing to build new systems by the January deadline. In the lawsuit, the states say the change came “contrary to months of regular communications with CMS and preliminary guidance materials upon which Plaintiff States based their implementation plans.” They also say CMS still hasn’t given states enough clarity on how they can update their systems appropriately. Bureaucracy, as usual, lands hardest on the people who can least afford a missed form or a bad interpretation.
What the Rule Really Does
This month’s CMS announcement caught states off guard with a new definition of medical frailty. The law had said medically frail people include those who have substance use disorders, disabilities or serious medical conditions. But the CMS rule went further, saying someone’s condition must “significantly impair” their ability to work, volunteer or attend school at the rates required in the law for them to get an exemption.
That shift matters because the agency also set up a future proof burden. In 2027 and once in 2028, the patient can attest that they meet the definition. But when they try to renew coverage in 2028, they’ll need to prove it. Health analysts and state Medicaid directors have said they aren’t clear on what existing documentation could prove that point. The apparatus wants paperwork, not people.
The plaintiffs wrote that “Added administrative burdens will cause individuals who are eligible for Medicaid to lose or be denied coverage.” They added: “People with disabilities, patients in the middle of cancer treatment, or those struggling with another serious or complex health condition, shouldn’t be at risk of losing the care that helps maintain their health.” Those are the people forced to navigate the maze while the rulemakers sit behind the desk.
The State Says 'Commonsense'
Kinda Serafi, a partner at the legal and consulting firm Manatt Health who is working with states to make the changes, said the administration “moved the goalposts” with its rule on medical frailty. “By going beyond the clear language of the statute, CMS opened the door to this court challenge,” she said.
New York Attorney General Letitia James, one of the Democrats suing the administration, said the new rule puts thousands of her state’s residents at risk. “New Yorkers who are battling cancer, living with a disability, managing a serious mental health condition, or recovering from addiction should be able to get the health care they need without being buried in paperwork,” she said in a statement.
Spokespeople for the U.S. Department of Health and Human Services and CMS didn’t immediately respond to a request for comment. The Trump administration has promoted the new rules as commonsense measures to eliminate government freeloading and preserve benefits for those who need them most. That’s the language of discipline dressed up as fairness, with the state deciding who counts and who gets pushed out.