On a quiet Wednesday night in Boston, a federal judge didn’t stop one of the most important changes to health policy under Trump. There was no big deal or dramatic moment in court. Just a decision that will hurt millions of low-income Americans who depend on Medicaid to stay insured.
Twenty-five states and Washington, D.C. asked Judge Richard J. Stearns, who was appointed by Bill Clinton, to temporarily stop the Trump administration’s Medicaid work requirement rule. He said no. Chronically ill Medicaid patients must show that they are medically too weak to work, volunteer, or do other “community engagement” activities for at least 80 hours a month, or they could lose their coverage. This rule comes from Republicans’ One Big Beautiful Bill Act. The deadline of January 1 for implementation stays the same.
The states said they were really losing money because they had to spend millions of dollars hiring new staff and setting up new technology systems just to follow the rules. Stearns agreed that the deadline was short, but he said that it was set by Congress, not the Trump administration. When asked about the cost, he said that the federal government had promised to pay 90% of the states’ implementation costs. This, he thought, was enough to weaken the case for emergency aid. He wrote that the last 10% of costs did not amount to “irreparable harm” that would make it right to block the rule completely.
Even so, Stearns turned down the injunction “without prejudice,” which is a careful legal signal. It was clear that he knew the case was very complicated, and he told states they could come back if new evidence of harm came to light. His writing made me think a lot about whether CMS Administrator Mehmet Oz (yes, that Dr. Oz) followed the rules that Congress actually gave him permission to follow when he wrote a stricter medical frailty standard than what the law itself said. Those questions aren’t going away. They will only be argued again later, when the case is ready for summary judgment and more facts are known.
What’s happening on the ground at this very moment is what makes it feel really uncomfortable. Already overworked state health departments are reportedly telling people that tens of thousands of people who signed up for Medicaid through the Affordable Care Act’s expansion may need to bring a note from their doctor to keep their insurance. That’s not just a guess. Starting in a few months, that’s the system that people will have to use.
People in the medical field have reacted with something close to alarm. In a letter to CMS, America’s Physician Groups, which represents more than 260,000 clinicians, said that the rule makes doctors decide for their patients whether or not they can work, which is not something doctors are trained to do and is also not the right thing to do. In a brief sent to the court, the American Medical Association said that the rule was likely to hurt doctor-patient relationships and add more work for doctors who are already very busy. It’s tough not to believe that. It’s already hard to get primary care in this country, and it’s not easy to add a fitness-to-work test to every Medicaid visit.
As this plays out, it seems like the real argument hasn’t happened yet. That was made clear by the court. A faster briefing schedule is being made so that the pros and cons can be looked at before the January deadline. States can still ask for emergency aid again if the process takes too long after December 31. It’s still not clear how this will end. The administration is counting on work requirements to get hundreds of billions of dollars back in federal spending over the next ten years and cut millions of people from Medicaid. These are not small goals. Laws and practical issues about what “medically frail” means and who makes that decision are still very much up in the air.
