Alice Thornton has spent more than two decades treating people living with HIV in Lexington, Kentucky.
Her team tends to “cringe” anytime they hear about patients having to fill out lots of paperwork, like when applying for Social Security Disability payments, because it can be a difficult, burdensome process.
Thornton tries to support her patients, she said, but understands the limits of her training.
“A lot of times the forms are so complex that I don’t really know what’s the true definition of what this form is asking me,” she said. “We refer them to a disability provider.”
Doctors including Thornton worry they’ll see more of those kinds of requests because of coming changes to Medicaid, the government health insurance program for people with low incomes or disabilities. Starting Jan. 1 in most of the country, some enrollees — mainly adults without dependents — must prove they’re working or performing other qualifying activities 80 hours a month.
Final regulations issued in June say people can obtain an exemption if they’re “medically frail,” or too sick or disabled to work, which may require them to submit documentation from a medical professional. That standard prompted a lawsuit at the end of June from dozens of mostly Democratic-led states and has Thornton worried it could force her and her staff to assess things like how much a patient can lift or how far they can walk.
“If I’m asked, ‘Is this person medically frail?’ What does that even mean?” Thornton said. “I don’t know, and I’ve been doing this for 25 years.”
Last year’s GOP tax-and-spending law known as the One Big Beautiful Bill Act established the work rule, which will affect an estimated 18.5 million Americans when more states start enforcing it. The mandate is expected to cause a larger increase in the number of people without health insurance than any other part of the law, notes KFF, a health information nonprofit that includes KFF Health News.
Doctors say they aren’t trained to accurately assess whether someone’s health keeps them from working. Many don’t have time to handle another administrative task that takes them away from patient care. And being involved in whether someone gains access to a public benefit undermines the doctor-patient relationship, several doctor groups and physicians said.
“When you introduce unnecessary, non-evidence-based, confusing, and bureaucratic policies like this into clinical care, it just raises the level of moral distress for providers,” said Christopher Chen, a senior healthcare adviser at the consulting firm Manatt.
The Centers for Medicare & Medicaid Services declined to respond on the record about doctors’ concerns. But the agency confirmed that enrollees may need to get documentation from a clinician to prove they’re too sick to work and said states would make final determinations.
The Trump administration has previously said states should use available data sources — such as medical claims and payment data — before making patients submit proof of medical frailty from a provider.
“Documentation should be relatively easy to provide,” Mehmet Oz, the CMS administrator, said during a June 1 press call.
But deciding whether a patient is too sick to work is a subjective, high-stakes decision, said Chen, who also practices as a hospitalist at Valley Medical Center in Renton, Washington.
“We’re trained to take care of people,” he said. “We’re trained to learn about someone’s symptoms, make diagnoses, treat them. We’re not trained to make these kinds of work determinations.”
When they apply and every six months after, Medicaid enrollees subject to the rule will have to prove that they’re performing the minimum monthly hours of qualifying activities — or will likely have to prove as frequently that they qualify for an exemption.
If states can’t find sufficient evidence that someone is too sick to work, that person will be able to self-attest to it under penalty of perjury — but only for a short time. States may take someone’s word that they’re medically frail twice in 2027 and only once in 2028.
Last month, 25 mostly Democratic-led states sued the Trump administration over the final regulations, arguing the medical frailty standard would be too hard for enrollees to meet — and for states to assess.
The standard, they argue, requires state Medicaid agencies to “take on the role of occupational medicine experts” or adds that burden to physicians who are not necessarily trained in occupational medicine.
CMS declined to comment on the litigation.
The Trump administration has crusaded against fraud in government health programs including Medicaid. It recently charged hundreds of defendants — including medical professionals — over more than $6.5 billion in alleged fraud schemes.
CMS has said it will keep a close watch on how states administer the work requirements and may take corrective action if states step out of line.
That has doctors concerned about the potential repercussions if they incorrectly assess whether someone is too sick to work, as farfetched as those worries might be, said Rahul Vanjani, a primary care and addiction medicine physician and researcher at Brown University.
“We, using our imaginations, wonder if someone is auditing these forms in the background and if they’re going to reach out to the licensing board.”
The country is short thousands of primary care providers, and it could be hard for people seeking an exemption to find a clinician to help them document that they’re too sick to work, doctors said.
It will be even more challenging for someone without insurance, said Jennifer Wagner, who researches Medicaid eligibility at the left-leaning Center on Budget and Policy Priorities.
“How could an applicant who doesn’t have health coverage get a doctor’s note?” she asked.
The American Medical Association, the nation’s largest professional association of doctors and medical students, lobbied federal officials to change the standard for documenting medical frailty in the days before the final regulations were made public.
In May, the AMA sent a letter to Oz, the CMS administrator, arguing that forcing doctors to attest to their patients’ ability to work wouldn’t just be an administrative headache but would affect the way they interact with those in their care.
In a statement, the association’s president, Willie Underwood III, said the work rule “transforms the clinical encounter into an eligibility gatekeeping process.”
“Patients will likely sense that shift,” he said. “And if they begin to suspect that what they share with their physician could affect their coverage, the conditions for open and honest communication will start to break down.”
Doctors have a fixed amount of time to spend with patients and would rather focus on treating medical conditions than filling out forms, especially ones that put them in a position to “represent the state,” said John Ayanian, an internal medicine physician and researcher at the University of Michigan.
“Their first obligation is to serve the best interest of their patients,” Ayanian said.
Lauren Davis, an attorney with Community Legal Services of Philadelphia, helps clients navigate other public benefit programs, such as the Supplemental Nutrition Assistance Program, which has a similar work rule. Enrollees can get an exemption from it if they’re too sick to work.
She recalled a client with a cognitive condition that affected her memory. The client’s doctor wasn’t comfortable filling out an exemption form without seeing her in person, but she kept forgetting to make an appointment and eventually gave up, said Davis, who worries Medicaid enrollees could face similar barriers to getting exemptions.
“This person is eligible,” Davis said. “The reason that they’re not able to get what they need to show that they’re eligible is because of their medical condition.”
