On Monday, the Centers for Medicare and Medicaid Services released its interim final rule on Medicaid work requirements, mandating that everyone who seeks Medicaid support has to prove they are unable to work to a greater extent, even if they have already been diagnosed with a debilitating condition like sickle cell disease—and even if they are already on Medicaid.

Federal Medicaid work requirements are being implemented as part of President Trump’s so-called One Big Beautiful Bill, a budget and spending bill which is also cutting nearly a trillion dollars from Medicaid’s budget over the next decade.

In states with Medicaid expansion, an Affordable Care Act provision that allows more low-income people to access Medicaid, the legislation mandated that work requirements be implemented, but didn’t resolve certain details of how and who would be targeted—questions the Department of Health and Human Services has now answered in the most restrictive possible way. The Urban Institute estimates that between 4.9 and 10.1 million fewer people could be enrolled in Medicaid by 2028 as a result of work requirements and more frequent eligibility checks. The interim final rule is likely to yield a figure at the high end of that estimate. Medicaid work requirements have to be implemented in all states with Medicaid expansion by January 1, 2027, though some Republican-led states have opted to do so ahead of schedule.