Eliza Brader worries she soon will need to prove she’s working to continue receiving Medicaid health coverage. She doesn’t think she should have to.

The 27-year-old resident of Bloomington, Indiana, has a pacemaker and a painful joint disease. She also has fused vertebrae in her neck from a spinal injury, preventing her from turning her head.

Indiana’s Medicaid agency currently considers Brader “medically frail,” giving her access to an expanded set of benefits, such as physical therapy.

New federal rules will require more than 18 million Medicaid enrollees nationwide to show they’re working, volunteering, or going to school for 80 hours a month starting in 2027 to keep their coverage. Brader is exempt as long as she’s deemed medically frail.

But lacking sufficient federal guidance, states are wrestling with how to define medical frailty — a consequential decision that could cut Medicaid coverage for many people, said state officials, consumer advocates, and health policy researchers.

“It’s terrifying,” Brader said. “I already have fought so hard to get my health care.”

‘Incredibly High’ Stakes

President Donald Trump’s One Big Beautiful Bill Act slashes nearly $1 trillion from Medicaid over the next decade, with much of the savings projected to come from no longer covering those who don’t qualify under the new work rules. Those spending cuts help offset the costs of GOP priorities, such as extra border security and tax cuts that mainly benefit the wealthy.

Conservative lawmakers have argued that Medicaid, the government health insurance program for people with low incomes or with disabilities, has grown too large and expensive, especially in the wake of its expansion to more low-income adults under the Affordable Care Act. They also say that requiring participants to work is common sense.

The work rules in Trump’s tax-and-spending law offer exemptions for several groups who might struggle to meet them, including people deemed “medically frail.” The law spells out certain “medically frail” conditions such as blindness, disability, and substance use disorder. But it does not list many others.

Instead, the law exempts those with a “serious or complex medical condition,” a term whose interpretation could vary by state.

State officials say they need more clarity to ensure that people who cannot work for health reasons retain rightful access to Medicaid. They also worry that, even with a clear definition, people will face the onerous task of having to regularly vouch for being medically frail, which is a challenge without reliable access to medical care.

“The stakes are incredibly high,” said Kinda Serafi, a partner at consulting firm Manatt Health.

The new work requirements will affect Medicaid recipients in 42 states and Washington, D.C. Eight states — Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming — did not expand their Medicaid programs to cover additional low-income adults, so they won’t have to implement the work rules.

The Medicaid work rules are expected to be the largest driver of health insurance coverage losses over the next decade, according to the nonpartisan Congressional Budget Office.

Forty-four percent of all adults covered by states’ expanded Medicaid programs have at least one chronic health condition, according to KFF.

A Challenge for States

State Medicaid agencies are scrambling to implement the rules with little direction from the U.S. Department of Health and Human Services, which has yet to issue specific guidance. Federal officials will clarify the “medically frail” definition next year, said Andrew Nixon, an agency spokesperson.

Ultimately, states will have to decide who is unhealthy enough to be exempt from work rules. And it won’t be easy for state workers and their computer systems to track.

Every year, state eligibility systems screen millions of applicants to check if they qualify for Medicaid and other government programs. Now, these same systems must screen applicants and existing enrollees to determine whether they meet the new work rules.

Jessica Kahn, a partner at consulting firm McKinsey & Co., has urged states to start planning how to adapt eligibility systems to verify work status. States can do a “tremendous amount” of work without direction from the federal government, said Kahn, a former federal Medicaid systems official, who spoke during a recent Medicaid advisory panel hearing. “Time is a-wasting already.”

State Medicaid directors are pondering the challenge.

“Medical frailty gets so complex,” Emma Sandoe, Oregon’s Medicaid director, said during a recent panel discussion. Conditions that can keep people from working, such as mental health disorders, can be hard to prove, she said.

A state might try to use a person’s health records, for instance, to determine medical frailty. But a patient’s chart may not paint a clear picture of someone’s health, especially if they lack regular access to medical care.

It’s a tall order for eligibility systems that historically have not had to scrape medical records to screen applicants, said Serafi of Manatt Health.

Lobbying groups for the private health insurance companies that help run Medicaid in many states also have urged federal regulators to clearly define medical frailty so it can be applied uniformly.

In a Nov. 3 letter to federal officials, the Medicaid Health Plans of America and the Association for Community Affiliated Plans advocated for allowing enrollees to qualify for the exemption by saying on their applications that they have conditions that make them medically frail. Successfully implementing exemptions for the medically frail will be “crucial” given the “severe health risks of coverage loss for these populations,” the groups said.

Some state officials worry about the unintended consequences of the work rules for people with chronic conditions.

Jennifer Strohecker, who recently resigned as Utah’s Medicaid director, reiterated the high stakes, especially for those with diabetes on Medicaid. They may be very healthy and functional with insulin, but if they fail to complete the work requirements, that may change, Strohecker said during a recent Medicaid advisory hearing.

Whether someone is deemed medically frail already depends heavily on where they live.

For example, in Arkansas, people indicate on their Medicaid applications that they’re disabled, blind, or need help with daily living activities.

Approximately 6% of the roughly 221,000 people enrolled in Arkansas’ Medicaid expansion program are deemed medically frail, according to Gavin Lesnick, a spokesperson for the Arkansas Department of Human Services.

In West Virginia, the state accepts a medical frailty designation when an applicant self-reports it.

The burden of proof is higher in North Dakota. Applicants there must answer a questionnaire about their health and submit additional documentation, which may include medical chart notes and treatment plans. More than half of applicants were denied last year, according to Health and Human Services Department spokesperson Mindy Michaels.

Indiana’s Family and Social Services Administration, which runs its Medicaid program, declined an interview and said it could not comment on individual cases, like Brader’s.

Brader worries the additional red tape will cause her to lose Medicaid again. She said she was temporarily kicked off the program in 2019 for failing to meet the state’s work rules when Indiana said her work-study job didn’t count as employment.

“Anytime I have tried to receive help from the state of Indiana, it has been a bureaucratic nightmare,” she said.

As states await federal guidance, Kristi Putnam, a senior fellow at the conservative Cicero Institute and former secretary of the Arkansas Department of Human Services, which oversees the state Medicaid program, said even if a state creates an extensive list of qualifying “medically frail” conditions, the line must be drawn somewhere.

“You can’t possibly create a policy for exemptions that will catch everything,” she said.

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No tax holidays but increased dollars for the Department of Child Services highlight the House Republican version of the state’s two-year budget in comparison to the one proposed by Gov. Mike Braun earlier this year.

Chief budget architect for Republicans, Rep. Jeff Thompson, said both camps found plenty to agree upon, aligning priorities for universal school vouchers and halting several large-dollar funds for the Indiana Economic Development Corp.

“We’ve looked at the governor’s budget and he’s done a wonderful job of setting the framework for opportunity for Hoosiers,” said Thompson, R-Lizton. “We’ll continue discussion with him, consulting with him and look forward to working with him in the future.”

Both the House and governor’s version trim roughly 5% from agency budgets, which Thompson said would be geared toward administrative costs rather than staff or service reductions.

“The way this administration is operating, we’ll do a whole lot more with a whole lot less,” Thompson said. “That’s their mindset and I love that mindset.”

Overall, the House budget will spend $500 million more in 2026 and $380 million more in 2027 than Braun, though the bulk of new spending goes to the Department of Child Services and the Department of Correction. Those new dollars represent just under 2% of a $47 billion budget.

Budget specifics

The appropriation for schools increases by 2% each year, or from $9.03 billion in the 2025 fiscal year to $9.21 billion in 2026 followed by $9.4 billion in 2027. The $160 million for curricular materials is rolled into that foundational amount for schools.

Those dollars also include an estimated $183 million over the next two years to expand school vouchers to all students, including those families earning more than $220,000 annually. Thompson said public schools, where the majority of Hoosier students are educated, could get those dollars if they attract those high-income students.

“If they attract more students, they will get a lot more money. It’s a good thing, because we may have some schools really gaining students and they’ll receive a lot more funds and they’ll have those to spend,” Thompson said.

That philosophy hews closely to Braun, who is a vocal “school choice” advocate. The budget also increases both Education Scholarship Accounts and Career Scholarship Accounts from $10 million to $15 million each year.

But while Braun had identified $700 million in tax relief, much of those dollars won’t carry over to the House’s version. Tax holidays for school and youth athletic supplies as well as outdoor recreational equipment didn’t survive and neither did a proposal to eliminate state income taxes on tips and retirement income.

The House did double the tax credit for low-income seniors. About 335,000 Hoosiers earning under $40,000 qualified for the $500 credit in 2022, which will double to $1,000 under this budget.

Thompson pointed to the General Assembly’s commitment to lowering Indiana’s income taxes to 2.9% by 2027 as well as ongoing property tax relief negotiations. More tax relief isn’t off the table, he said.

Identifying cuts

Both Braun and House Republicans struck funds for the Indiana Economic Development Corp., including a site acquisition and deal closing line items — though Thompson said the quasi-public state agency wouldn’t be barred from such activities within their own budget.

The caucus did, however, restore funding for the 21st Century Research and Technology Fund and the Manufacturing Readiness Grants that Braun had cut. They will be flatlined to the same amounts from the last budget.

In a blow to the state’s local public health departments, funding for Health First Indiana will fall from $150 million this year to $100 million in both 2026 and 2027. Prior to its implementation, Indiana spent some of the least amount of state dollars on public health initiatives nationwide.

Additionally, House Republicans opted not to appropriate more funding to eliminate Medicaid waiver waitlists for services.

“Nothing changes with regard to where we sit now,” said Thompson about Medicaid waitlists.

Medicaid is the second-largest and fastest-growing portion of the state budget, accounting for 22% of state spending — or $10.3 billion — over the next biennium.

Fifteen years ago, Medicaid made up just 9% of the state budget.

The state partners with the federal government to administer Medicaid, with roughly one-third of Medicaid expenses coming from the state’s budget. But the funding from the federal government could be at risk, depending on the actions of the new administration.

“We are watching that closely and continue to watch that. We can’t control that, you know, but we’ll keep our eye on that because that, at some point, may have an effect on the state,” Thompson said.

Whether to reserve more in savings to prepare for such uncertainty was an “ongoing discussion,” he said.

A separate waitlist for subsidized child care will also remain in place, though Thompson said the budget appropriates dollars to keep current participating families covered.

The House version includes very little in terms of one-time spending, especially for capital projects. Federal pandemic funds boosted such spending in recent years, including a multi-billion dollar prison in northern Indiana.

“No capital (projects) for universities, but there are a lot of dollars for maintenance. We believe it becomes dead if you don’t take care of your current facilities and we put a lot of dollars into taking care of those facilities,” Thompson said.

Overall higher education funding remains relatively flat compared to previous year but higher than the amount budgeted under Braun’s version.

The Senate will introduce its own version in the coming weeks, with both sides negotiating a final budget in mid-April following an updated revenue forecast.

“I’m going to say nothing’s off the table. But from what I know, (with) a lot of those things, we probably won’t see a lot of change,” Thompson said. “This would be, I think, a good place for the Senate to start. They’ll improve it — we know that — and then we’ll work with the governor’s office to make it the best for Hoosiers.”

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The Indiana Capital Chronicle is an independent, nonprofit news organization dedicated to giving Hoosiers a comprehensive look inside state government, policy and elections. The site combines daily coverage with in-depth scrutiny, political awareness and insightful commentary.

You can read the original version of the story here.

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INDIANAPOLIS — Gov. Mike Braun's directive for Medicaid providers to cease all advertising on TV and radio in the state is getting a lot of pushback from local broadcasters throughout the state.

"Unfortunately, all you are doing is punishing small businesses in Indiana," said Dave Arland with the Indiana Broadcaster Association. "Having a revenue stream cut off like this does have an impact."

The directive laid out by Braun earlier this week urges Medicaid providers to stop buying advertising on TV and radio stations in an effort by the Braun administration to wean people off of Medicaid. He believes this avenue will work towards saving the state money.

However, Arland tells WISH-TV that many local broadcasters rely on this advertising revenue, especially in a day and age where cutbacks have become somewhat of a norm in the industry.

"We feel singled out, quite frankly," he said. "We don't think it's appropriate to simply cut off TV and radio advertising. "There are contracts that have been put in place with the agencies that buy this [commercial] time and they have called and said, ‘stop’. And we feel that’s inappropriate."

The IBA represents nearly 200 radio and television stations across the Hoosier state, which collectively employ 48,000 employees. The National Broadcasters Association has even taken notice of the issue, saying that the directive may even have "significant First Amendment concerns" since they say this is essentially a government agency directing a business to stop advertising a legal service.

"It would be good to have a better explanation," Arland said. "Is this temporary? Is this permanent? How does this help us address our Medicaid issue in the state?"

At the moment roughly two million Hoosiers rely on Medicaid. That's around one out of every four Hoosiers. Braun and other state leaders are looking to narrow a nearly $1 billion Medicaid funding shortfall the state is contending with.

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WARSAW -- Thousands more Hoosiers left the state’s Medicaid rolls during the second month of “unwinding” federal protections, according to the latest report from the Centers for Medicare and Medicaid Services.

More than 53,600 Hoosiers lost their government insurance coverage in May in addition to the nearly 53,000 who lost coverage in April.

Of the 165,431 Hoosiers up for renewal in May, nearly 40% were renewed; another 6% were no longer eligible; 27% were dropped for procedural reasons; and the renewal process for the remaining 28% is pending. Percentages are rounded.

Roughly 82% of Hoosiers whose coverage lapsed lost Medicaid due to procedural reasons, such as an incomplete form, a decrease from nearly 89% the month before.

Though more Hoosiers were up for renewal in May compared to April, the number who kept their insurance remained relatively flat, at 65,092 in April and 65,882 in May.

The 91,000 combined Hoosiers who fell off of the Medicaid rolls due to procedural reasons have 90 days to finalize paperwork and may even qualify for retroactive coverage. However, state policy doesn’t permit Hoosiers under the Healthy Indiana Plan to be retroactively covered.

Previously, the state estimated that between 300,000 and 400,000 Hoosiers could lose their coverage over the entire period but if dis-enrollment rates from the first two months hold that number could be much higher — closer to 600,000.

Hoosiers whose coverage lapsed or who have questions about their eligibility in the coming months should contact the Family & Social Services Administration (FSSA). To learn more, visit the FSSA Medicaid website.

A nationwide process

During the COVID-19 Public Health Emergency, the federal government offered a boost to Medicaid payments in exchange for states giving every recipient continuous coverage, regardless of income changes. Medicaid agencies like FSSA saw their budgets swell and simultaneously saved money with less administrative burdens.

At the same time, the growth of state Medicaid rolls surged. In Indiana alone, the number of Hoosiers using the government insurance program grew from 1.4 million prior to the pandemic to more than 2.2 million in April.

Following the expiration of the COVID-19 Public Health Emergency, states began the “unwinding” process, where agencies redetermined eligibility for hundreds of thousands of enrollees.

In the first month, half a million Americans lost coverage across 11 states, including Indiana. Florida accounted for roughly half of the decrease, but Indiana — tied with Arkansas — had the highest disenrollment rate for procedural reasons.

Indiana’s performance relative to other states improved in the most recent analysis from June 16. But the state still reported a higher disenrollment rate for procedural reasons than the national average, of 74%.

However, the majority of states started their “unwinding” process after Indiana, which was one of 19 states whose review began in May or earlier. Another 22 states began in June and nine more will start in July. One state, Oregon, won’t begin its process until October.

KFF estimates that between 17 and 24 million people nationwide could fall off the Medicaid rolls. Another study from the nonprofit found that a majority of recipients had no idea about the renewal process, especially Black recipients.

Actions in Indiana

FSSA has attempted to combat this discrepancy through a series of actions, including a collaboration with Black churches to promote and educate.

Michele Holtkamp, the director of communications for FSSA, noted the procedural terminations can include someone losing coverage because they died, moved out of state or were incarcerated. Some who don’t finish their forms could know they no longer qualify and abandon the process or voluntarily withdraw for other reasons.

“We are taking multiple steps to try to reach people. In addition to our statewide advertising campaign, we continue engaging with stakeholders in communities across the state weekly to help them work directly with Hoosiers. We continue to text and call members at risk of losing coverage, and partner with the managed care entities and hospitals to help them understand who is at risk so they can help,” she said.

Holtkamp urged Medicaid beneficiaries to contact FSSA’s Division of Family Resources and update their information. Additionally, some children may remain eligible even if their parents no longer qualify.

“We continue to be deeply concerned about the high rate of Medicaid dis-enrollments impacting Hoosier kids and families, and hope that FSSA will use every tool at their disposal, including those recently made available by CMS, to reduce unnecessary healthcare coverage loss. Because so many Hoosier families and the majority of Hoosier kids rely on Medicaid to fill prescriptions and get the care they need, it’s essential that Hoosiers come together across race and place to push for a Medicaid system that keeps as many of us as possible covered,” Hutchings-Goetz said in a statement.

The federal government details the “unwinding” process suggestions Indiana participates in to limit the number of procedural dis-enrollments, including collaborating with the Postal Service and ex parte, or automatic, renewals for select populations.

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The Indiana Capital Chronicle is an independent, nonprofit news organization dedicated to giving Hoosiers a comprehensive look inside state government, policy and elections. The site combines daily coverage with in-depth scrutiny, political awareness and insightful commentary.

You can read the original version of the story here.

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