This post is about a proposed change in the Medicaid rules that govern the designation of someone as medically frail and thus unable to work. The new rule would require Medicaid recipients to prove they are unable to work even if they are on disability.
As many of you know, I am a long time advocate for the National Alliance on Mental Illness, better known as NAMI. They have issued a nationwide alert requesting people write to the federal government commenting on a proposed rule regarding work requirements for people who are “medically frail.” I agree with NAMI that this rule change would have devastating consequences for people on disability who are reliant on Medicaid for their mental health care. So I am writing to you about it in hopes you will make a public comment by July 31st, which is this Friday.
The federal law passed last year that made huge cuts to Medicaid included the imposition of work and/or community engagement requirements on Medicaid recipients. In the past, Medicaid recipients who were on disability were deemed “medically frail.” The new federal legislation didn’t eliminate this category but the administration has proposed a rule that would require everyone on disability to prove that they are unable to work, attend school, volunteer, or do other qualifying activities in order to retain their Medicaid benefits. They would have to do this at least every twelve months with the rule allowing states to require it as frequently as every six months if they wanted.
While the law includes exemptions for some people, the new rules will require that people prove they are also unable to work. The Kaiser Family Foundation wrote about the proposed rule last week (you can read their analysis here.) The proposed rule would require that even those identified in the legislation that made cuts to Medicaid and imposed work requirements as medically frail must meet an additional test: their condition must significantly impair their ability to consistently work or engage in community engagement activities.
The episodic nature of many severe mental health conditions puts people with mental health conditions at risk of being determined ineligible despite records that show that attempts to work triggered relapses in the past. States are barred from looking back more than 12 months in their efforts to use existing data such as previous encounters to determine medical frailty.
The proposed rule promises audits of states to verify they are complying with what is a vague definition of medical frailty and virtually no directions about how they are to determine medical frailty with financial penalties levied if states are found to be out of compliance. Given this administration’s policy of punishing blue states at every opportunity in any way they can, it is easy to see how this aspect of the rule could be used to bludgeon blue states for failing to “comply.”
On June 29, 2026 twenty-five states and the District of Columbia sued the federal government over the proposed rule. It will take time for this lawsuit to work its way through the courts, something this administration regularly counts on to get away with violating laws that stand in the way of their punishing the poor for being poor and blue states for offering higher levels of benefits.
Implementation of this rule would undo decades of progress made toward providing stable, accessible, community-based behavioral health services because of its impact on local funding. Community-based outpatient programs rely heavily on Medicaid funding to operate. Given the likelihood that many people would lose their benefits due to their inability to meet the requirements of the proposed rule or due to their inability to negotiate the new bureaucratic burden (which is likely to include the requirement that providers verify the person’s inability to work every twelve months) local programs will struggle to sustain their programs. Individuals would once again have to wait until they were in crisis to receive life-saving medical care. The ultimate cost of this proposed rule, if implemented, far outweighs any possible potential savings and appears to be a short-sighted vindictive attempt to punish people for being disabled.
NAMI sent out an urgent alert last week asking people to make public comment on the proposed rule by July 31, 2026. A link to their alert, which contains a link that makes it easy to make public comment on this issue, can be found below. It’s hard to know how much these kinds of efforts make a difference but it is one of the few things within our power as individuals that we can do to put our values into action and protect ourselves and our loved ones.
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