Judge blocks Trump administration’s Medicaid rule forcing sick recipients to prove they can’t work

Halfpoint Images/Moment RF/Getty Images

Chronically ill people on Medicaid won’t be bound by new work requirement rules that the latest Trump administration guidance requires in order to qualify for “medically frail” exemptions, a federal judge ruled Thursday.

US District Judge Richard Stearns in Boston gave a partial victory to a coalition of 25 states and the District of Columbia, which sued the Trump administration in June over the Centers for Medicare and Medicaid Services guidance linked to the One Big Beautiful Bill Act. The 2025 law instituted the first-ever federal work requirement in Medicaid.

The law says the definition of medically frail must include people who are blind or disabled, have substance use disorders or disabling mental disorders, have certain disabilities that significantly impair daily activities, or have serious or complex medical conditions. But the CMS rule went further, requiring people in those categories to show that their conditions also “significantly impair” their ability to comply with the law’s work requirements.

Issued in June, the rule took many states and advocates by surprise since CMS had not indicated in its informal guidance that it would take a harder line. States, already under a tight deadline to stand up the work requirement program by January 1, have been racing to get their systems ready. The medically frail interpretation required them to make additional changes, and the judge’s ruling will now force them to shift directions again.

Advocates had worried that the CMS rule would add major paperwork burdens to patients, who could have had to provide proof that their conditions prevent them from working. Further complicating matters was that the severity of these enrollees’ medical conditions — and the impact on their ability to work — can vary over time.

The provision could also have put doctors in a tough spot, since they may have been called upon to help determine whether someone is able to work, which would affect their patients’ coverage.

The plaintiffs argued that the stricter rule would prevent eligible Americans from accessing the care they need — and overstep the text of the law itself. The judge agreed that they met the burden of irreparable harm.

“Because 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 States (and public) face potential for great hardship in the absence of an injunction,” Stearns said.

KFF: U.S. poised to boot thousands of legal immigrants from Medicaid

The ruling is likely to mean some people will be able to obtain or keep coverage, said Morgan Henderson, an economist who studies Medicaid at the Hilltop Institute at the University of Maryland, Baltimore County.

“Those individuals who would have lost coverage because they’re sick but they’re not quite sick enough,” he said, “they might have their coverage preserved now.”

North Carolina Health and Human Services Secretary Dr. Dev Sangvai said it would also help patients avoid some stressful situations.

“One of our top priorities is to make sure people can get the critical health care they need without facing confusing paperwork or the fear of losing coverage during treatment,” he said in a statement. “This decision allows us to focus on what matters most: delivering reliable health care to our state’s most vulnerable residents when they need it most.”

But Stearns did not give the states a complete victory. He upheld two other federal restrictions on how states can verify medical frailty, including the requirement that states reject proof of patients’ medical frailty if the diagnosis is more than a year old. He also upheld a policy allowing states to accept only one self-attestation per continuous period of enrollment.

Explaining why he upheld the portions in favor of the government, Stearns said “the government provided a non-frivolous rationale for adopting each provision and explained why it did not find the States’ concerns of disenrollment compelling.”

CMS declined to comment.

Shannon Stapleton/File/Reuters

More than 3 million Medicare Advantage enrollees need to find new plans for 2027 in third year of turmoil

The new Medicaid restrictions are part of Trump’s big tax and policy law in 2025. The change affects those covered through an expansion in most states that gave more lower-income people access to the government’s safety net healthcare program.

Starting January 1, expansion enrollees ages 19 to 64 must show that they work or do community service at least 80 hours a month or are in school at least half the time. There are exceptions for those considered medically frail or in addiction treatment programs, among others. Some states, including Nebraska and Montana, have already started enforcing the mandate.

Some 5.3 million more people are expected to be uninsured in 2034 because of the work requirement, according to a Congressional Budget Office estimate from last summer.

The Associated Press contributed to this report.

Halfpoint Images/Moment RF/Getty Images

一位联邦法官周四裁定，患有慢性疾病的医疗补助计划受益人将不受特朗普政府最新指导意见中规定的“医疗虚弱”豁免资格所需的新工作要求规则的约束。

美国波士顿地区法官理查德·斯特恩斯 (Richard Stearns) 裁定，由25个州和哥伦比亚特区组成的联盟取得部分胜利。该联盟于6月就与《一项宏伟法案》(One Big Beautiful Bill Act) 相关的联邦医疗保险和医疗补助服务中心 (CMS) 指南对特朗普政府提起诉讼。这项将于2025年实施的法案首次在联邦医疗补助计划 (Medicaid) 中引入了工作要求。

法律规定，医疗虚弱的定义必须包括失明或残疾、患有药物滥用障碍或致残性精神障碍、患有某些严重影响日常生活能力的残疾，或患有严重或复杂疾病的人。但美国医疗保险和医疗补助服务中心（CMS）的规定更进一步，要求这些类别的人证明他们的病情也“严重损害”了他们履行法律规定的工作要求的能力。

这项于6月发布的规则令许多州和倡导者感到意外，因为联邦医疗保险和医疗补助服务中心（CMS）在其非正式指导意见中并未表明会采取更强硬的立场。各州原本就面临着在1月1日前启动工作要求计划的紧迫期限，因此一直在争分夺秒地完善系统。对“医疗脆弱”的解释要求他们做出额外的调整，而法官的裁决现在将迫使他们再次改变方向。

倡导者们曾担心，CMS的这项规定会给患者增加繁重的文书工作负担，他们可能需要提供证据证明自己的病情导致无法工作。更复杂的是，这些参保人员的病情严重程度及其对工作能力的影响会随时间而变化。

该规定也可能让医生陷入两难境地，因为他们可能被要求帮助确定某人是否能够工作，这会影响到他们的病人的医疗保险。

原告辩称，更严格的规定将阻止符合条件的美国人获得所需的医疗服务，并且违背了法律条文本身的意图。法官同意原告的说法，认为他们证明了该规定造成了不可弥补的损害。

斯特恩斯说：“由于强制执行‘医疗虚弱’的非法定义可能会导致原本符合条件的弱势群体失去资格，而这些弱势群体依靠医疗补助计划来获得持续的护理，因此，如果没有禁令，各州（和公众）可能会面临巨大的困难。”

KFF：美国准备将数千名合法移民从医疗补助计划中剔除

马里兰大学巴尔的摩分校希尔托普研究所研究医疗补助的经济学家摩根·亨德森表示，这项裁决可能意味着一些人将能够获得或保留医疗保险。

他说：“那些因为生病但病情还没到需要休医保的程度而失去医保的人，现在或许可以保住他们的医保了。”

北卡罗来纳州卫生与公共服务部部长德夫·桑瓦伊博士表示，这也有助于患者避免一些压力较大的情况。

他在一份声明中表示：“我们的首要任务之一是确保人们能够获得所需的关键医疗保健，而无需面对繁琐的文书工作或治疗期间失去医保的担忧。这项决定使我们能够专注于最重要的事情：在最需要的时候，为我们州最弱势的居民提供可靠的医疗保健。”

但斯特恩斯并未让各州取得彻底胜利。他维持了另外两项联邦限制，这些限制涉及各州如何核实患者的医疗脆弱性，其中包括要求各州拒绝接受诊断超过一年的患者医疗脆弱性证明。他还维持了一项政策，该政策允许各州在每个连续参保期内只接受一份自我声明。

斯特恩斯解释了他为何支持政府的部分，他说：“政府为采纳每一项条款提供了合理的理由，并解释了为什么政府认为各州对取消入学资格的担忧并不令人信服。”

CMS拒绝置评。

Shannon Stapleton/档案/路透社

在动荡的第三年，超过300万参加联邦医疗保险优势计划（Medicare Advantage）的人员需要为2027年寻找新的保险计划。

新的医疗补助限制是特朗普2025年重大税收和政策法案的一部分。这项变化影响到大多数州通过扩大医疗补助覆盖范围而获得保障的人群，这些扩大使更多低收入人群能够获得政府的安全网医疗保健计划。

自1月1日起，19至64岁的扩容计划参保人员必须证明他们每月工作或参与社区服务至少80小时，或至少一半时间在校学习。身体虚弱或正在接受戒瘾治疗的人员等可获得豁免。包括内布拉斯加州和蒙大拿州在内的一些州已经开始执行这项规定。

根据国会预算办公室去年夏天的估计，由于工作要求，预计到 2034 年将有约 530 万人失去医疗保险。

美联社对本报道亦有贡献。