A federal judge in Boston ruled Thursday that the Trump administration broke the law when it told states that a Medicaid patient with cancer, HIV or a disabling mental illness is not “medically frail” unless she also proves the condition “significantly impairs” her ability to work. Judge Richard Stearns, in a 16-page decision in Commonwealth of Massachusetts v. Oz, found that the Centers for Medicare and Medicaid Services had no authority to narrow a definition Congress wrote, and that enforcing it “may lead to the disenrollment of otherwise eligible vulnerable individuals relying on Medicaid coverage for continuity of care.”
Every account of the ruling says who won. None of them says how many people the definition decides. That number is not in the ruling, and the administration has never published it, so here is the arithmetic from the public record. KFF counts more than 20 million adults covered through Medicaid expansion, the population the work rules hit on January 1. The last time states reported what share of those adults they classified as medically frail, in KFF’s 2018 survey, the answers ran from 0.3 percent in New Jersey and 1.4 percent in Massachusetts to 8 percent in Arkansas and Montana and 24 percent in Indiana. Apply that spread to 20 million and the exemption Stearns just protected covers somewhere between 60,000 and 4.8 million people, depending entirely on which state’s practice becomes the national one. That spread is the whole fight. A definition is a lever, and the administration had its hand on it.
The Terms of the Deal
Read the ruling the way you would read a term sheet, because that is what it is. The states got the main thing. The law Trump signed last year says the medically frail exemption must include people who are blind or disabled, people with substance use disorders or disabling mental disorders, people with disabilities that significantly limit daily activity, and people with “serious or complex medical conditions.” CMS’s June rule added a second test on top: the condition must also significantly impair the person’s ability to meet the 80-hour monthly work requirement. Stearns held that the agency’s reading of significant impairment went beyond its powers and was contrary to law, and he gave states a six-month stay on their frailty determinations so they can rebuild verification systems that had been coded to the illegal standard.
The government kept two things, and they are not small. States may refuse medical evidence older than a year. And a patient may self-attest to frailty only once per continuous enrollment period, after which paperwork is due at renewal. Stearns let both stand because “the government provided a non-frivolous rationale for adopting each provision.” Non-frivolous is a low bar. It means the one-year paperwork clock and the single attestation survive, which means a woman whose oncologist last wrote a letter 13 months ago starts the new year outside the exemption until she gets another one.
The work requirements themselves were never on the table. Starting January 1, expansion adults aged 19 to 64 in 43 states must log 80 hours a month of work, community service or school, or qualify for an exemption, to keep coverage.
Who Was on Each Side of the Table
The plaintiffs were 25 states and the District of Columbia, led by the attorneys general of California, Massachusetts and New Jersey. The defendant is Dr. Mehmet Oz, the television physician who runs CMS. The same judge declined to freeze the rule in July, on the ground that the states had not shown their system-rebuilding costs were unrecoverable; by Thursday he had reversed his view of the harm, writing that “the States (and public) face potential for great hardship in the absence of an injunction.”
What changed between July and October is the record. CMS’s own interim final rule runs about 400 pages and, as KFF pointed out when it landed, it gave states no list of diagnoses and no severity criteria. A state could not exempt everyone with cancer, HIV, Parkinson’s or multiple sclerosis. It had to assess each person’s capacity to work. The rule did not define frailty. It defined a process for denying it.
The Leverage Was Always the Coverage Numbers
Here is the part the agency does not say out loud. The reason to narrow the exemption is not administrative tidiness. It is the coverage losses, which are the savings, which are the point. The Congressional Budget Office estimated the work requirements would push about 5.2 million people off Medicaid by 2034. CMS’s own projection for its rule was about 3.3 million at full ramp-up. Manatt Health, modeling the rule state by state, found the frailty narrowing and the other verification limits would add about 1.8 million people a year to the losses already baked into the statute, lifting the annual average from 6.4 million to 8.2 million.
Every person pushed out of the medically frail category is a person who now has to document 80 hours a month or lose coverage, and the people least able to produce that documentation are, by definition, the sick ones. That is the design. Arkansas ran this experiment in 2018 and 18,164 people lost coverage in seven months, the large majority for failing to report rather than failing to work.
We think the ruling is correct and insufficient. Correct because an agency does not get to rewrite a statutory floor into a ceiling, and Stearns said so plainly. Insufficient because the one-year evidence clock and the single-attestation rule he left in place do the same work more slowly, and because the work requirement itself, which no court is going to strike, is the machine the definition was bolted onto. We wrote earlier this year that these cuts would land hardest on the rural hospitals and clinics that depend on Medicaid billing to stay open. The frailty rule was the administration’s attempt to make the law cut deeper than Congress wrote it. The responsible parties are Oz, who signed the rule, and the White House that needed the savings to pay for last year’s tax bill.
What Happens on January 1
The administration will almost certainly appeal to the First Circuit, and it has 60 days to do it. In the meantime the six-month stay gives states until roughly the end of April to rebuild their frailty screens around the statute instead of the rule, which is three months after the work requirements switch on. Patients in that window will be living under two definitions at once, and the ones who get caught in the gap will not be reading court opinions.
The honest thing for CMS to do is publish the number it has never published: how many of the 20 million expansion adults it expected to lose the exemption under its definition. It modeled the coverage losses, so it knows. Until it says, the range above, 60,000 to 4.8 million, is the only one on the public record, and the width of that range is the clearest measure of how much power the agency was trying to take.