Kelli Austin isn’t sure she could consistently work 80 hours per month.

Her body won’t let her.

“There are days I can’t get out of bed,” said Austin, 38, of Waterville. “There are days I can’t use the bathroom on my own.”

She has numerous physical and mental health conditions and is able to work part-time — usually 50 to 100 hours per month. But starting as soon as January 2027, she’ll have to work 80 hours each month to keep her Medicaid insurance.

“Without Medicaid, what would I do?” Austin said. “I would be dead.”

The new work requirements drive much of the expected $911 billion in Medicaid cuts in the Republican budget bill approved last month and signed into law by President Donald Trump.

Under the new rules, adult Medicaid enrollees will need to prove they are working, volunteering or attending school to remain eligible for insurance. It would require older adults, caregivers and parents of children age 14 and older to work while balancing care for themselves or others.

An estimated 90,000 adults would be subject to work requirements under MaineCare, Maine’s Medicaid program. Maine Department of Health and Human Services officials predict more than 31,000 Mainers could lose insurance in the first year as a result of eligibility hurdles and other challenges.

Health policy experts warn that the work requirements will be especially detrimental for Maine’s seasonal workers, older adults, caregivers and people living in rural areas without work opportunities. With hospital closures and funding cuts embroiling Maine’s health care system, they say the requirements threaten to displace more Mainers from accessing care.

Trump administration officials have defended the requirements, arguing that people should not receive free health care if they are unwilling to work part time, attend school or volunteer. Other proponents of the law see work requirements as a way to get non-working, able-bodied adults into the workforce.

But states that have previously approved work requirements for Medicaid in recent years, including Georgia and Arkansas, found the costs needed to run the programs ballooned state budgets, and the rules did not spur an expansion of the workforce, according to analyses by national health policy think tanks KFF and the Robert Wood Johnson Foundation.

Maine Department of Health and Human Services officials estimate the new requirements will cost the state $8 million to implement and $5.5 million annually after they launch, according to a recent Maine DHHS fact sheet issued after the bill passed in July.

“The work requirements make it harder for people to stay engaged in the workforce,” said James Myall, an economic policy analyst for the Maine Center for Economic Policy, a progressive think tank.

CHALLENGES FOR VULNERABLE PEOPLE

Some individuals are exempt from the work requirements under the new law. They include: pregnant people; those who qualify for Social Security disability benefits; those participating in a substance use treatment program; people 19 and under or 65 and older, and those who are parents or caretakers of a disabled person or a child age 13 and under.

But health policy experts warn that many people remain vulnerable to losing their insurance. Caregivers of adults as well as people with physical and mental conditions that aren’t severe enough to qualify for disability are at risk, said Darcy Shargo, CEO of the Maine Primary Care Association, a membership organization that advocates for community health centers across the state.

“Those are folks that are going to have a really difficult time trying to get an exemption,” Shargo said.

Older adults will also be required to work or volunteer 80 hours each month or lose access to Medicaid. Jess Maurer, executive director of the Maine Council on Aging, which leads a statewide network to advocate for older people, said many will struggle to meet requirements.

“It is definitely not going to be a good thing for older people,” she said. “Between the ages of say, 50 to 64, these are the folks who are definitely more likely to be out of work, either because of ageism, because they’ve lost their job, because their employer thinks they’re too old, or their body has just broken down over time.”

If they can’t meet work requirements now, she said, a growing portion of people will eventually enter Medicare (available to those 65 and older) missing a decade of preventative care, and that will add to costs down the line.

Carter Friend, CEO of Nasson Health Care, a community health clinic in Springvale, said 43% of Nasson’s patients have Medicaid insurance. Without those patients, Nasson will lose revenue, and some of the patients will stop seeking care.

Maurer said the work requirements will “have a chilling effect” and people will end up without health insurance.

“They’ll be sicker, and we’ll all pay,” Maurer said. “I mean, free care isn’t actually free. Somebody pays in the end.”

‘WITHOUT MEDICAID WHAT WOULD I DO’

Dr. Mehmet Oz, the Trump administration’s Centers for Medicare and Medicaid Services administrator, said in a recent interview with Fox Business, that people can find many ways to meet the work requirements.

“Prove that you matter,” Oz said. “Do something that shows you have agency over your future.”

Austin, the woman from Waterville, worries she can’t meet that burden.

She works part-time as a peer recovery coach at Assistance Plus in Winslow and earns $17.75 per hour. She also picks up seasonal work at L.L.Bean when she can.

Her hours vary. Some months she may work 100 hours. Other months it may only be 50 or 60. She said it depends on what hours her employers need and whether she’s physically able to work that much.

“With my jobs, it’s unpredictable,” Austin said. “I don’t know how many hours I’m going to work.”

She doesn’t seem to meet any of the work requirement exemptions, and said having Medicaid is what has allowed her to work.

While sipping a large coffee at a cafe in Topsham this month, Austin showed a reporter a three-page list of her current medical conditions as compiled by her doctor’s office. A partial list includes two autoimmune diseases, hereditary neuropathy, rheumatoid arthritis, fibromyalgia, bipolar disorder, anxiety, attention-deficit disorder and nerve pain.

She takes at least nine different medications, which would cost thousands of dollars out-of-pocket. Austin also takes Suboxone as maintenance treatment for a previous opioid use disorder.

She could possibly qualify for Social Security disability, but said she doesn’t want to do that.

“I don’t want to be the person who sits at home and collects a check. I want to contribute to society,” said Austin, who also volunteers for Maine Equal Justice advocacy group.

People living with mental illnesses or substance use disorders may also find it difficult to work consistent hours, said Jayne Van Bramer, president and CEO of Sweetser, a Maine mental health nonprofit.

“These are not folks who can get up every day and go to work at the same time and produce at the same level, because these illnesses are often episodic,” Van Bramer said. “So you might have a period of time where your symptoms have really flourished and you’re not able to work, or you might only be able to work two hours a day, or maybe only 10 hours a month, but you can’t hit this threshold of 80 hours a month.”

For Adrian Jarvis, 27, chronic back pain has left them currently unable to work full-time. They also need to take care of their mental health conditions. Jarvis said being able to work part-time while getting gender-affirming care and surgery through Medicaid has helped their mental health improve.

“It’s made my life more livable,” said Jarvis, who works part-time at a nonprofit called Food and Medicine, and is also a part-time student.

Jarvis said they may improve enough to be able to work full-time by the time the work requirements kick in, but it’s hard to tell if that will be the case.

“I’ve been in and out of physical therapy for a few years,” Jarvis said. “It’s been hard to get better. There’s no easy answers.”

‘THE DEVIL’S REALLY IN THE DETAILS’

Verification barriers, unreliable internet access and other challenges are expected to cause tens of thousands of Mainers to fall through the cracks and lose coverage in the first year of the new work rules, health policy experts say.

According to the Maine DHHS fact sheet, many people may be kicked off of Medicaid not because they don’t qualify or have an exception, but because of the burdensome paperwork requirements. Many seasonal or temporary roles do not use traditional time sheets — leaving workers who do meet requirements unable to prove it.

Lindsay Hammes, a spokesperson for the Maine DHHS, said in an email that the agency will need to hire more workers — it’s not clear yet how many — to enforce the new law.

“While the department will attempt to automate as much of the process for eligible applicants as possible,” staff will be needed to “manually verify exemptions or volunteer verifications, especially for people who have multiple jobs, work in seasonal industries, or work irregular hours,” Hammes wrote.

With MaineCare officials likely to be overwhelmed and under-staffed, Shargo said the responsibility of helping patients report work requirements could fall on providers at Maine’s community health centers, which serve one in every six MaineCare enrollees.

Starting Jan. 1, 2027, state officials will be required to redetermine every six months whether Medicaid enrollees are eligible for an exemption. If the state fails to verify an exemption, that individual will have 30 days to show compliance before being disenrolled.

The law exempts people who are “medically frail” and have a “disabling medical disorder,” but does not specify how state officials should define and verify those exemptions.

“The devil’s really in the details,” said Bryan Wyatt, chief public affairs officer at the Maine Primary Care Association. He said the organization has used scenario planning to predict the impact of work requirements on community health centers in Maine.

Even with an automated verification process, which automatically exempts individuals, Wyatt said up to 36% of adult MaineCare patients at community health centers would lose coverage due to reporting complexities.

CAREGIVERS IMPACTED

While the law provides exceptions for people who serve as caregivers for adult relatives, it’s unclear how difficult it will be to obtain an exemption. Myall, of the Maine Center for Economic Policy, said the rules to qualify for the adult caregiver exemption have not yet been spelled out.

Myall said unpaid caregivers “prop up the economy” and if they become uninsured and fall ill, that can have ripple effects on society. It can weigh down the economy and cause health care costs to increase as people put off care while uninsured, he said. Then they become sick and can no longer support their relative, Myall said.

In 2023, Maine had 166,000 caregivers providing an estimated $2.9 billion in unpaid care, according to the AARP Public Policy Institute, which analyzes issues around aging. That care workforce is dominated by women — whether they work in a long-term care facility, care for a sick family member or are the primary caretaker of a dependent child, Wyatt, with the Maine Primary Care Association, said.

According to a survey conducted as part of the Maine State Plan on Aging Needs Assessment, 85% of Maine caregivers are women.

Robyn Stanicki, of Unity, works full-time for the city of Bangor, but said she may have to move to part-time if her family’s problems with MaineCare persist. She and her wife have four children, two of whom are adults living with disabilities. Her family relies on MaineCare for some or all of their health coverage.

Stanicki said she received a letter in January that her 14-year-old son, Evan, who is diagnosed with autism, will no longer be eligible for MaineCare. Each week, Evan receives around 16 hours of behavioral health therapy, which Stanicki says is only available through MaineCare. She said she does not know why her son lost eligibility.

If Evan loses services, Stanicki said she could have to drop down to part-time work to care for him — risking her own health insurance.

“Honestly we would probably fall apart,” she wrote in a text message. “I would be trying to find loopholes or do anything to get back on MaineCare, up to and including taking a job at McDonald’s for the minimum amount of time that I would need to work to get under the qualifying threshold.”

Austin has a 16-year-old daughter and helps care for her partner’s two teenagers.

“I want to be there for them, make their lunch for school, go to work and just be able to function,” Austin said. “It’s an uphill battle.”

Sun Journal Staff Writer Kendra Caruso contributed to this report.