Abstract
BACKGROUND: Federal Medicaid work requirements, recently enacted under national legislation, are expected to cause substantial disenrollment among low-income adults. However, the public health consequences of these policies remain poorly quantified. METHODS: Extending our previously developed modeling framework, we projected national and state-level excess mortality and uncontrolled morbidity attributable to Medicaid coverage loss among expansion enrollees. Our three coverage loss scenarios were based on Congressional Budget Office projections and disenrollment patterns observed in Arkansas and New Hampshire. We incorporated administrative variation in automatic exemption capacity and reporting compliance. Mortality estimates used hazard ratios comparing insured and uninsured adults, while morbidity estimates focused on uncontrolled diabetes, hypertension, and high cholesterol. FINDINGS: We estimate between 7049 and 9252 excess deaths annually under the three national scenarios. We also project up to 113,607 additional cases of uncontrolled diabetes, 135,135 of hypertension, and 37,800 of high cholesterol. State-level excess deaths range from under 20 to over 2,100, with per-capita mortality highest in the District of Columbia and states such as New York and New Mexico. State performance varies widely based on administrative capacity. For example, North Carolina and Rhode Island would avert over 90 percent of deaths that could be avoided through stronger exemption systems, while Pennsylvania and South Dakota may only avert fewer than 30 percent. INTERPRETATION: Medicaid work requirements are projected to increase mortality and chronic disease burden across the United States. These findings highlight the role of state administrative capacity and underscore the public health cost of restricting insurance access. FUNDING: Notsew Orm Sands Foundation.