The promise was rock solid, lawmakers insisted. No cancer patient would lose coverage. The medically frail would be protected. The work requirements applied only to able-bodied adults who choose not to work.
The promise was a lie.
The Trump administration released its 400-page rule for Medicaid work requirements Monday, and the fine print reads like a death warrant for some of the most vulnerable Americans.
The “medical frailty exemption” — the very mechanism designed to protect patients with cancer, heart disease, and other catastrophic illnesses — has been narrowed so severely that even people in active cancer treatment may be forced to document 80 hours of monthly work or lose their insurance.
“This rule is catastrophic for cancer patients,” said Dr. Gwen Nichols, chief medical officer of Blood Cancer United, a patient advocacy group. “It breaks lawmakers’ promises.”
The three Republicans who represent New Jersey in Congress—Tom Kean Jr., Chris Smith, and Jeff VanDrew—voted in favor of the federal reconciliation bill and other budget legislation that mandate work and community engagement requirements for able-bodied, working-age adults on Medicaid.
The rule, mandated by the One Big Beautiful Bill Act passed last year, requires able-bodied adults aged 19 to 64 to work, volunteer, attend school, or pursue job training for at least 80 hours per month. Enrollees must verify their eligibility twice a year instead of once.
Kean, a 57-year-old Republican, hasn’t voted or been seen in public for three months, and one New Jersey Democratic lawmaker who unsuccessfully tried to reach out to Kean said on the condition of anonymity, “No one has any idea what’s f—– going on with him? Like, literally no one knows.”
Kean’s office defended the requirements as steps to cut down on waste, fraud, and abuse in the system, but the work rules drew sharp criticism from state officials and healthcare advocates, who argued they could put health coverage at risk for nearly 700,000 “able-bodied” adults in New Jersey’s Medicaid program.
“Congressmen Jeff Van Drew, Chris Smith, and Tom Kean Jr. gutted Medicaid for New Jersey families to stuff another tax break into billionaires’ pockets,” said Medicare for All advocate Lisa McCormick. “That is not representation. That is robbery.”
And here is the cruel heart of it: To qualify as medically frail — the exemption lane — patients must now produce written proof of a severe medical condition, certified in a way the rule does not clearly define.
That means a mother undergoing chemotherapy, a father with Stage 4 lung cancer, a grandmother with advanced heart failure. They must navigate paperwork. They must convince a bureaucrat that they are sick enough to be excused from working 20 hours a week. And if the paperwork is late, or the doctor’s note is worded wrong, or the state contractor loses the file, the coverage disappears.
This is not speculation. It happened before. Arkansas implemented work requirements during the first Trump administration. The result: massive coverage losses and no measurable increase in employment. Georgia tried a version: small coverage gains at prohibitive cost. And patients died while waiting for approvals they never received.
Brian Becker, a 32-year-old father and leukemia patient in Texas, died while waiting for Medicaid. His family received the denial letter after his funeral.
The administration’s own estimates project that 5.3 million people could lose coverage under these rules. The federal savings: $326 billion. The human cost: incalculable.
Critics, including the New Jersey Department of Human Services and New Jersey Citizen Action, strongly opposed Kean’s vote, arguing that it imposes unnecessary bureaucratic hurdles and creates barriers to healthcare for vulnerable working families.
Republican lawmakers, including House Energy and Commerce Chair Brett Guthrie, made assurances that exemptions would protect the seriously ill. “Our bill couldn’t be clearer,” Guthrie wrote.
Van Drew was one of a dozen House Republicans who signed a letter to Guthrie saying Medicaid cuts could threaten nursing homes and hospitals, but the vulnerable South Jersey lawmaker voted for the cuts anyway.
“We support targeted reforms to improve program integrity, reduce improper payments, and modernize delivery systems to fix flaws in the program that divert resources away from children, seniors, individuals with disabilities, and pregnant women – those who the program was intended to help,” the letter said. “However, we cannot and will not support a final reconciliation bill that includes any reduction in Medicaid coverage for vulnerable populations.”
“Through his vote, Congressman Tom Kean, Jr. chose to stand with billionaires and corporations and declare war on our healthcare system and New Jersey’s working families,” said Laura Waddell, Health Care Program Director for New Jersey Citizen Action.
The rule says otherwise. And the rule is what takes effect July 31.
What happens to Amanda Brunson, the leukemia patient who dropped to 88 pounds during treatment and could not bathe herself, let alone hold a job? What happens to the veteran with PTSD, the mother caring for a disabled child, the worker whose cancer has returned?
They face a choice: prove they are sick enough to be excused from work, or prove they are working enough to keep their insurance. For many, neither proof is possible.
The administration contends the rules may push people into jobs, reducing poverty by nearly 3 million people. But no one has explained how a chemo patient attends job training. No one has explained how a dying man documents his disability before he dies.
There is still time. The rule does not take full effect until July 31, and Congress could correct it. But the machinery is moving. The paperwork is printing. And the most vulnerable Americans are being handed a pen they cannot hold and a deadline they cannot meet.
The Trump administration is taking a tough stance on one of its hallmark and most debated health initiatives: new work requirements that could push millions of low-income individuals off Medicaid.
Among adults 65 with Medicaid who don’t get benefits from Social Security disability programs like SSI or SSDI, and who aren’t covered by Medicare, 92% were either working full or part-time (64%) or not working because of caregiving duties (12%), illness or disability10%), or being in school (7%).
The new rules make it harder for states to decide who qualifies for an exemption, even stating that having a serious illness like HIV or cancer doesn’t automatically free someone from meeting the requirement of 80 hours per month of paid work, volunteering, or attending school.
Meanwhile, another rule would hand political appointees much more control over who receives health and science grant funding, as well as which political activities recipients can take part in.
This marks a big shift — right now, most decisions are made by career scientists and outside peer reviewers, purely on scientific merit rather than alignment with an administration’s political goals.
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