2026年2月11日 / 美国东部时间凌晨5:00 / KFF健康新闻
洛丽·凯利（Lori Kelley）的视力不断恶化，这让她很难找到稳定的工作。
这位59岁的女性居住在北卡罗来纳州哈里斯堡，去年她关闭了自己的非营利性马戏艺术学校，因为她的视力已经不足以完成文书工作。之后她曾在一家披萨店制作面团，目前在当地一家音乐会场地分拣包括易拉罐和瓶子在内的可回收材料。这是她的主要收入来源——但这份工作并非全年都有。
“这里的人认识我，也喜欢我，”凯利这样评价她的雇主，“我不需要向这里的人解释为什么我看不懂（文书）。”
凯利住在一辆露营车里，每年收入不到1万美元。她说这是可能的，部分原因是她拥有《医疗补助》（Medicaid）的健康保险，该保险支付关节炎和焦虑症药物费用，并让她能够定期看医生以控制高血压。
但她担心明年会失去这份保险，届时新规定将生效，要求包括凯利在内的数百万人每月至少工作、志愿活动、上学或从事其他符合条件的活动80小时。
“我现在很害怕，”她说。
北卡罗来纳州哈里斯堡的洛丽·凯利因视力恶化影响了生计。去年，她因视力不足以处理文书工作不得不关闭了自己的非营利性机构。根据新的《医疗补助》工作要求，凯利担心自己将失去高血压和焦虑症治疗的医疗保障。A.M.斯图尔特（A.M. Stewart）/ KFF健康新闻
在新的医保政策改变被签署成为法律之前，共和党议员曾暗示年轻、失业的男性正在利用这项为数百万低收入或残疾人群体提供保险的政府项目。众议院议长迈克·约翰逊（Mike Johnson）在接受美国有线电视新闻网（CNN）采访时表示，《医疗补助》不应成为“29岁男性躺在沙发上玩电子游戏”的福利。
然而，健康信息非营利组织KFF的《医疗补助与无保险人群项目》副主任詹妮弗·托尔伯特（Jennifer Tolbert）表示，实际上，50至64岁的成年人，尤其是女性，可能会受到新规定的沉重打击。托尔伯特指出，对凯利和其他类似情况的人来说，工作要求将成为他们维持医保的障碍，许多人可能因此失去《医疗补助》，从而将自身的身体和财务健康置于危险之中。
从2027年1月开始，美国42个州和华盛顿特区的约2000万低收入美国人将需要满足活动要求才能获得或保留《医疗补助》健康保险。
阿拉巴马州、佛罗里达州、堪萨斯州、密西西比州、南卡罗来纳州、田纳西州、德克萨斯州和怀俄明州没有根据《平价医疗法案》（Affordable Care Act）扩大其《医疗补助》项目以覆盖更多低收入成年人，因此无需实施这些工作规定。
无党派的国会预算办公室（CBO）预测，在未来十年内，这些工作规定将导致至少500万人失去《医疗补助》保险覆盖。批评人士称，工作规定是共和党预算法案中导致医保覆盖损失的最大因素，该法案削减了近1万亿美元以抵消主要惠及富人的税收减免成本并增加边境安全。
“我们谈论的是以牺牲人们的生命为代价来省钱，”马萨诸塞大学波士顿分校老年病学研究员简·塔瓦雷斯（Jane Tavares）表示，“工作要求只是实现这一目的的工具。”
美国卫生与公众服务部发言人安德鲁·尼克松（Andrew Nixon）向KFF健康新闻表示，要求“有劳动能力的成年人”工作是为了确保《医疗补助》的“长期可持续性”，同时保护弱势群体。豁免对象包括残疾人、护理人员、孕妇和产后女性、完全残疾退伍军人以及其他面临医疗或个人困难的人群。
乔治敦大学研究人员指出，《医疗补助》的扩大为中年成年人提供了生命线，否则他们将缺乏保险。《医疗补助》覆盖了50至64岁每5个美国人中的1个，使他们在65岁符合《医疗保险》资格之前就能获得医保。
托尔伯特表示，在《医疗补助》覆盖的女性中，50至64岁年龄段的女性比年轻女性同龄人更难维持医保资格，并且更需要医疗服务。
托尔伯特解释说，这些中年女性不太可能达到规定的工作时长，因为许多人担任家庭护理人员或患有限制其工作能力的疾病。
塔瓦雷斯和其他研究人员发现，《医疗补助》总参保人群中只有8%被视为“有劳动能力但未工作”。这一群体主要是非常贫困的女性，她们因照顾家人而退出职场。在这一群体中，50岁以上的人占四分之一。
“她们不是无所事事的健康年轻人，”研究人员在报告中指出。
此外，托尔伯特表示，让人们更难维持《医疗补助》资格“实际上可能会削弱他们的工作能力”，因为他们的健康问题得不到治疗。不过她强调，即使这一群体失去医保，他们的慢性疾病仍然需要管理。
成年人往往在符合《医疗保险》资格之前就开始面临健康问题。
卫生政策研究人员表示，如果老年人在65岁之前没有经济能力处理健康问题，当他们符合《医疗保险》资格时，病情将会更严重，从而增加该项目的支出。
护理倡导者指出，许多50多岁或60岁出头的成年人不再工作，因为他们要全职照顾子女或年长的家庭成员，这一群体被称为“夹心一代”（sandwich generation）。
共和党预算法案确实允许某些护理人员免于《医疗补助》工作规定，但“豁免范围非常狭窄”，跨代关怀组织（Caring Across Generations）项目主任妮可·乔威克（Nicole Jorwic）表示。
她担心那些符合豁免条件的人会被遗漏。
“你会看到家庭护理人员病情加重，继续忽视自身健康，进而导致更多家庭陷入危机，”乔威克说。
63岁的宝拉·华莱士（Paula Wallace）来自阿肯色州奇德斯特（Chidester），她说自己成年后大部分时间都在工作，现在每天都在帮助丈夫管理晚期肝硬化。
在多年没有保险之后，她最近通过所在州的《医疗补助》扩大项目获得了医保，但这意味着她必须遵守新的工作要求才能保留医保。但她很难想象如何做到这一点。
“因为我是他唯一的护理人员，我不能外出离家工作，”她说。
华莱士表示，她的丈夫领取社会保障残疾保险（SSDI），法律规定作为全职照顾残疾人士的她应该被豁免工作规定。
但联邦官员尚未发布如何定义这一豁免的具体指导方针。而阿肯色州和佐治亚州（唯一实施过《医疗补助》工作项目的州）的经验表明，许多参保人难以应对复杂的福利系统。
“我非常担心，”华莱士说。
KFF健康新闻是一个全国性新闻机构，专门报道与健康问题相关的深度新闻，也是KFF（一个提供独立的健康政策研究、民意调查和新闻报道的非营利组织）的核心运营项目之一。
New Medicaid work rules likely to hit middle-aged adults hard
February 11, 2026 / 5:00 AM EST / KFF Health News
Lori Kelley’s deteriorating vision has made it hard for her to find steady work.
The 59-year-old, who lives in Harrisburg, North Carolina, closed her nonprofit circus arts school last year because she could no longer see well enough to complete paperwork. She then worked making dough at a pizza shop for a bit. Currently, she sorts recyclable materials, including cans and bottles, at a local concert venue. It is her main source of income ― but the work isn’t year-round.
“This place knows me, and this place loves me,” Kelley said of her employer. “I don’t have to explain to this place why I can’t read.”
Kelley, who lives in a camper, survives on less than $10,000 a year. She says that’s possible, in part, because of her Medicaid health coverage, which pays for arthritis and anxiety medications and has enabled doctor visits to manage high blood pressure.
But she worries about losing that coverage next year, when rules take effect requiring millions of people like Kelley to work, volunteer, attend school, or perform other qualifying activities for at least 80 hours a month.
“I’m scared right now,” she said.
Lori Kelley of Harrisburg, North Carolina, has deteriorating vision that affects her livelihood. Last year, she had to shutter her nonprofit because she couldn’t see well enough to do paperwork. Under Medicaid’s new work requirements, Kelley is concerned about losing access to care for her high blood pressure and anxiety. A.M. Stewart for KFF Health News
Before the coverage changes were signed into law, Republican lawmakers suggested that young, unemployed men were taking advantage of the government health insurance program that provides coverage to millions of low-income or disabled people. Medicaid is not intended for “29-year-old males sitting on their couches playing video games,” House Speaker Mike Johnson told CNN.
But, in reality, adults ages 50 to 64, particularly women, are likely to be hit hard by the new rules, said Jennifer Tolbert, deputy director of the Program on Medicaid and the Uninsured at KFF, a health information nonprofit that includes KFF Health News. For Kelley and others, the work requirements will create barriers to keeping their coverage, Tolbert said. Many could lose Medicaid as a result, putting their physical and financial health at risk.
Starting in January 2027, some 20 million low-income Americans in 42 states and Washington, D.C., will need to meet the activity requirements to gain or keep Medicaid health coverage.
Alabama, Florida, Kansas, Mississippi, South Carolina, Tennessee, Texas, and Wyoming didn’t expand their Medicaid programs to cover additional low-income adults under the Affordable Care Act, so they won’t have to implement the work rules.
The nonpartisan Congressional Budget Office predicts the work rules will result in at least 5 million fewer people with Medicaid coverage over the next decade. Work rules are the largest driver of coverage losses in the GOP budget law, which slashes nearly $1 trillion to offset the costs of tax breaks that mainly benefit the rich and increase border security, critics say.
“We’re talking about saving money at the expense of people’s lives,” said Jane Tavares, a gerontology researcher at the University of Massachusetts Boston. “The work requirement is just a tool to do that.”
Department of Health and Human Services spokesperson Andrew Nixon said requiring “able-bodied adults” to work ensures Medicaid’s “long-term sustainability” while safeguarding it for the vulnerable. Exempt are people with disabilities, caregivers, pregnant and postpartum individuals, veterans with total disabilities, and others facing medical or personal hardship, Nixon told KFF Health News.
Medicaid expansion has provided a lifeline for middle-aged adults who otherwise would lack insurance, according to Georgetown University researchers. Medicaid covers 1 in 5 Americans ages 50 to 64, giving them access to health coverage before they qualify for Medicare at age 65.
Among women on Medicaid, those ages 50 through 64 are more likely to face challenges keeping their coverage than their younger female peers and are likely to have a greater need for health care services, Tolbert said.
These middle-aged women are less likely to be working the required number of hours because many serve as family caregivers or have illnesses that limit their ability to work, Tolbert said.
Tavares and other researchers found that just 8% of the total Medicaid population is considered “able-bodied” and not working. This group consists largely of women who are very poor and have left the workforce to become caretakers. Among this group, 1 in 4 are 50 or older.
“They are not healthy young adults just hanging out,” the researchers stated.
Plus, making it harder for people to maintain Medicaid coverage “may actually undermine their ability to work” because their health problems go untreated, Tolbert said. Regardless, if this group loses coverage, their chronic health conditions will still need to be managed, she said.
Adults often start wrestling with health issues before they’re eligible for Medicare.
If older adults don’t have the means to pay to address health issues before age 65, they’ll ultimately be sicker when they qualify for Medicare, costing the program more money, health policy researchers said.
Many adults in their 50s or early 60s are no longer working because they’re full-time caregivers for children or older family members, said caregiver advocates, who refer to people in the group as “the sandwich generation.”
The GOP budget law does allow some caregivers to be exempted from the Medicaid work rules, but the carve-outs are “very narrow,” said Nicole Jorwic, chief program officer for the group Caring Across Generations.
She worries that people who should qualify for an exemption will fall through the cracks.
“You’re going to see family caregivers getting sicker, continuing to forgo their own care, and then you’re going to see more and more families in crisis situations,” Jorwic said.
Paula Wallace, 63, of Chidester, Arkansas, said she worked most of her adult life and now spends her days helping her husband manage his advanced cirrhosis.
After years of being uninsured, she recently gained coverage through her state’s Medicaid expansion, which means she’ll have to comply with the new work requirements to keep it. But she’s having a hard time seeing how that will be possible.
“With me being his only caregiver, I can’t go out and work away from home,” she said.
Wallace’s husband receives Social Security Disability Insurance, she said, and the law says she should be exempt from the work rules as a full-time caregiver for someone with a disability.
But federal officials have yet to issue specific guidance on how to define that exemption. And experience from Arkansas and Georgia ― the only states to have run Medicaid work programs ― shows that many enrollees struggle to navigate complicated benefits systems.
“I’m very concerned,” Wallace said.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.