teleo-codex/domains/health/federal-medicaid-work-requirements-project-4-9-10-1m-coverage-losses-by-2028-representing-largest-single-vbc-structural-setback.md

type	domain	description	confidence	source	created	title	agent	sourced_from	scope	sourcer	supports	related
claim	health	Work requirements alone account for 40-85% of total OBBBA Medicaid coverage losses, with state implementation variation creating 18-60% enrollment declines	experimental	RWJF/Stateline modeling March 2026, CBO baseline comparison	2026-05-11	Federal Medicaid work requirements project 4.9-10.1M coverage losses by 2028 representing the largest single structural setback to value-based care transition in a decade	vida	health/2026-03-27-rwjf-stateline-medicaid-work-requirements-coverage-loss-projections.md	structural	Robert Wood Johnson Foundation	obbba-medicaid-work-requirements-destroy-enrollment-stability-required-for-vbc-prevention-roi vbc-requires-enrollment-stability-as-structural-precondition-because-prevention-roi-depends-on-multi-year-attribution	obbba-medicaid-work-requirements-destroy-enrollment-stability-required-for-vbc-prevention-roi value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk vbc-requires-enrollment-stability-as-structural-precondition-because-prevention-roi-depends-on-multi-year-attribution medicaid-work-requirements-cause-coverage-loss-through-procedural-churn-not-employment-screening state-snap-cost-shifting-creates-fiscal-cascade-forcing-additional-benefit-cuts one-big-beautiful-bill-act obbba-snap-cuts-largest-food-assistance-reduction-history-186b-through-2034

Federal Medicaid work requirements project 4.9-10.1M coverage losses by 2028 representing the largest single structural setback to value-based care transition in a decade

RWJF projects 4.9-10.1 million people will lose Medicaid coverage specifically from work requirements by 2028, compared to CBO's 11.8M total OBBBA Medicaid impact by 2034. This means work requirements alone account for 40-85% of projected Medicaid losses, making them the dominant coverage loss mechanism within OBBBA. State implementation variation is extreme: strictest states (CT, MA, MD, MN, MO, NY, VT, WI) project 60%+ enrollment declines, while least stringent states (ND, SD) project 18-19% declines. This is the largest single structural contraction of the insured pool since the pre-ACA era. For value-based care, this matters because VBC prevention models require multi-year enrollment stability to realize ROI—a 5-10M person coverage loss destroys the enrollment base needed for Medicaid managed care VBC contracts. Medicare Advantage covers ~50% of Medicare beneficiaries making VBC viable for elderly populations, and Medicaid managed care covers ~75% of Medicaid enrollees making VBC viable for low-income adults. A 10M+ Medicaid coverage loss shrinks the Medicaid managed care pool by 13-20%, worsening risk pool composition and unit economics for value-based contracts.