Medicaid work requirements and cost-sharing under H.R.1: Implications for structurally vulnerable and medically...

Medicaid serves as the cornerstone of healthcare access for low-income and medically complex individuals in the United States. H.R.1, also known as the One Big Beautiful Bill Act, introduces sweeping federal Medicaid reforms, including $1 trillion in cuts, mandatory 80-hour monthly work requirements, and $35 co-pays per clinical service, that threaten to disenroll millions of beneficiaries. The implications of these changes for structurally vulnerable populations and student-run free clinics (SRFCs) remain poorly understood.

We conducted a retrospective cross-sectional study of adults (≥19) with active Medicaid coverage seen at Tulane University School of Medicine SRFCs from 2017-2025 using the TuPACT registry. Chronic illness burden (diabetes, hypertension, coronary artery disease [CAD], human immunodeficiency virus [HIV], hepatitis C virus [HCV], chronic obstructive pulmonary disease [COPD], cancer, and asthma) and structural risk factors (homelessness, history of incarceration, less than a high school education, and psychiatric illness) were identified. Patients were classified into four groups: ≥1 chronic condition, ≥2 structural risk factors, overlap (≥1 chronic condition + ≥2 structural risk factors), and neither. Outcomes included cost- or insurance-related barriers to care, primary-care physician (PCP) access, and chronic medication use. χ² tests and logistic regression were used for comparisons.

Among 1173 Medicaid-insured adults (mean age 43.4 ± 12.8 years), 47.9% had ≥1 chronic condition, 47.1% had ≥2 structural risk factors, and 23.7% met criteria for both (overlap group). Patients in the overlap group had significantly higher odds of reporting cost- or insurance-related barriers to care compared to all other groups (adjusted odds ratio [aOR] 3.11, 95% CI 1.48-6.53, p = 0.0027). Primary care access differed by group (p = 0.005), with 28.1% of overlap patients reporting no PCP, compared with 25.6% in the chronic condition group, 30.8% in the structural risk group, and 35.3% in the neither group; this association was not significant after adjustment. Chronic medication use demonstrated the greatest gradient across groups: 70.5% of overlap patients were taking ≥1 chronic disease medication, compared with 67.1% in the chronic condition group, 60.0% in the structural risk group, and 29.4% in the neither group (p < 0.0001). In adjusted analysis, overlap patients had higher odds of chronic medication use compared to all other groups (aOR 2.75, 95% CI 2.07-3.69). These findings indicate that individuals facing both chronic illness and structural vulnerability already experience substantial financial and access barriers that would likely be exacerbated by the work requirements and cost-sharing provisions outlined in H.R.1.

Patients at the intersection of medical complexity and structural vulnerability represent the segment of the Medicaid population least able to comply with work requirements and most susceptible to cost-related care avoidance. Even with active Medicaid coverage, many already face financial barriers and fragmented care. Implementation of H.R.1 would therefore disproportionately disenroll those most dependent on Medicaid, further destabilizing the safety-net system. Protecting Medicaid's role requires viewing coverage not as a privilege contingent on employment, but as an instrument of public health equity. For individuals experiencing homelessness, psychiatric illness, or incarceration history, work requirements and co-payments are not motivational tools, they are barriers to survival. Preserving coverage continuity for these groups is a public health imperative. Without deliberate safeguards, H.R.1 threatens to widen the very inequities that Medicaid was designed to close.