To keep the health insurance that is treating their cancer, some of the sickest people in America will soon have to prove they are too ill to hold down a job, and the Trump administration has just gone to court to keep it that way.
A federal judge on Thursday refused a request by more than two dozen Democratic-led states to block the administration's rules on who can be excused from new Medicaid work requirements, rules the states say are so narrow that people with terminal illnesses will have to actively document their own incapacity or risk losing coverage.
Government lawyers had urged the court to reject the states' challenge, and the judge agreed not to halt the policy, though he pointedly left the deeper legal questions unresolved. The requirements take effect on 1 January.
The Ruling and What the Judge Left Open
US District Judge Richard Stearns, sitting in Massachusetts, denied the states' motion for a preliminary injunction, allowing the administration's preparations to proceed ahead of the January deadline. But he was careful to frame the decision as procedural rather than final.
The denial 'is not a reflection or anticipation of its ultimate views on the merits of the underlying litigation', he wrote in the ruling, which will now continue.
Stearns acknowledged the case raised 'difficult issues' about how much power Congress had handed the health secretary to define who counts as too unwell to work, and about whether he had stayed faithful to what lawmakers intended.
He also noted that much of the pressure the states complained of flowed from the statute itself. 'This timeline was set by Congress in H.R. 1, not by CMS,' he wrote, referring to the Centres for Medicare and Medicaid Services.
The judge, an appointee of President Bill Clinton, added that the additional administrative costs the states face are largely reimbursable by the federal government at a rate of 90 percent, part of his reasoning for declining to find the irreparable harm an injunction requires.
The Fight Over Who Counts as 'Medically Frail'
At the heart of the dispute is a single phrase. The work requirements, created by the One Big Beautiful Bill Act that President Donald Trump signed in July 2025, oblige adults covered by Medicaid expansion to complete 80 hours a month of work, study or community service to keep their coverage. The law exempts people who are 'medically frail', but it left the administration to define the term.
The guidance the administration issued requires such a person to have a significant health condition and to be significantly impaired in their ability to work, a two-part test the states argue Congress never wrote and that sweeps too narrowly.
Under it, they say, low-income people with cancer, HIV, Parkinson's disease and other life-threatening conditions could be forced to affirmatively prove they are too sick to work in order to be spared the requirement.
Government attorneys countered that the statute delegated the definition to the federal government and that the states were trying to impose 'arbitrary limits' on that authority, adding that the plaintiffs had not met the legal standard for an injunction.
The framing of the row as one over terminally ill patients was sharpened in reporting by the progressive outlet Common Dreams, which highlighted the human stakes of the guidance.
A Policy With a Documented Track Record
The stakes are not theoretical, because a version of this experiment has already run. When Arkansas introduced Medicaid work requirements in 2018, during Trump's first term, a federal judge halted the policy within a year, but not before roughly 18,000 adults had lost their coverage, and later studies found the rules did not increase employment.
The scale this time is far larger. An analysis by the Urban Institute projects that between three and seven million people could lose Medicaid coverage nationally because of the new requirements, many of them, critics warn, not because they fail to qualify but because they are tripped up by the paperwork of proving they do.
The litigation continues, and the states may yet prevail on the merits even after losing this first round.
For now, though, the policy stands, and the clock the judge attributed to Congress keeps running towards a January morning when the requirement to prove one's own sickness becomes, for millions, a condition of staying insured.
