More than two dozen states sued the Trump administration this week over a regulation on new Medicaid work requirements, arguing that the guidelines are inconsistent with the law and will result in many sick and poor Americans losing coverage.
The coalition of 25 states and the District of Columbia is asking a federal court in Massachusetts to block parts of the regulation, which spells out how states must put in place the work requirements passed by Congress last year.
The law says that beginning in 2027, adults without disabilities or young children would need to work, volunteer, or go to school at least 80 hours a month to be eligible for Medicaid. But the law also detailed a number of exceptions for certain categories of people, including those Congress described as “medically frail.”
The Trump administration had been informally telling states that it could look to patients’ diagnoses to decide who was frail enough to be exempt from the work requirement. But in early June, federal Medicaid officials released a regulation with much stricter requirements. The rule said a diagnosis of a serious illness, such as cancer, end-stage renal disease or H.I.V./AIDS, would not be enough by itself to qualify for an exemption. States would also need to find that the health problem “significantly impairs” their ability to work.
The states, which have Democratic governors or attorneys general, contend that the rule will harm Medicaid beneficiaries, who will need to complete more paperwork to make their case to qualify for an exemption. Those who cannot navigate the system could lose their coverage.
“People with disabilities, patients in the middle of cancer treatment, or those struggling with another serious or complex health condition shouldn’t be at risk of losing the care that helps maintain their health,” the states wrote in their brief.
They argue that the new requirements will be nearly impossible for states to put into place by the end of the year. The unexpected changes mean states will need to build systems for evaluating people’s ability to work, a function few Medicaid offices currently perform.
Medicaid covers about 67 million Americans who are poor or disabled. The Congressional Budget Office has estimated that about five million Medicaid beneficiaries would become uninsured after the work requirement goes into effect.
A federal Medicaid spokeswoman declined to comment on the pending litigation, but Trump officials have broadly defended the work requirement rule as striking the right balance between protecting the sick and promoting work for those who are able.
“The exemption ensures that work expectations are directed to those who can participate and protecting those fully who cannot,” said Dan Brillman, who oversees Medicaid for the Trump administration, at the time the rule was published.
The coalition of states are making a two-part argument. First, they contend that the Trump administration’s narrow exemption for medical frailty is in conflict with the statute.
They also argue that the Centers for Medicare and Medicaid Services, the federal agency that oversees public health programs, violated the Administrative Procedure Act by backtracking on earlier guidance that indicated it would allow a broader medical frailty exemption.
States are “feeling like the rug was pulled out from under them,” said Katie Keith, director of the Center for Health Policy and Law at Georgetown Law School’s O’Neill Institute.
The lawsuit describes a slide deck that federal officials presented to state Medicaid officials in November 2025, saying that it intended to use a definition of medically frail that did not check whether an individual was able to work.
It also notes that the Trump administration allowed Nebraska to start its work requirement in May with a wider definition of medical fragility that did not require enrollees to prove they were too sick to work. Instead, they just needed to have certain diagnoses.
A few weeks before releasing the work requirement rule in early June, Mr. Brillman sent state leaders an email telling them to disregard previous advice.
“There are several areas where changes have been made to the preliminary policy previously shared,” he wrote, according to an email The New York Times previously reported.
Nicholas Bagley, a University of Michigan professor who has written extensively on the Administrative Procedure Act, said he thought the states made a persuasive case.
“I think this is a pretty darn good claim,” he said.
The suit also challenged the regulation’s approach to other key issues on the work requirements that were changed late in the process, including the degree to which people could swear to their medical issues or other grounds for exceptions.
The states have asked the courts to block provisions of the regulation by July 31, one month before they are supposed to send Medicaid beneficiaries notices about the work requirements.
Were that to happen, the Trump administration could rush to put out a new regulation, postpone enforcement of some provisions of the law or delay the implementation of work requirements.
The law includes a provision for states to obtain an extension on the work requirements until 2029 if they are struggling to comply but making a “good faith” effort. But, so far, the agency has told states they are unlikely to obtain them.
