Judge Richard D. Stearns, a Bill Clinton appointee on the US District Court of Massachusetts, issued a 16-page ruling on October 29, 2026, rejecting the Trump administration’s narrower definition of who is medically frail enough to avoid Medicaid work requirements.
Stearns ruled that the administration’s guidance went beyond the authority Congress gave it in the One Big Beautiful Bill Act and was “thus contrary to law.” His decision permanently blocks the restrictive language and gives the plaintiff states a six-month stay of enforcement.
The case was brought in June 2026 by a coalition of 25 states and the District of Columbia, co-led by Massachusetts Attorney General Andrea Joy Campbell. The states challenged the administration’s interim final rule as exceeding what Congress had authorised.
Congress passed the One Big Beautiful Bill Act in 2025. It requires Medicaid expansion enrollees aged 19 to 64 to work or do community service at least 80 hours a month, or attend school at least half the time, from January 1, 2027. The law provides exceptions for people considered medically frail and for people in addiction treatment programmes.
The law says medically frail people must include those who are blind or disabled; people with substance use disorders or disabling mental disorders; people with certain disabilities that significantly impair daily activities; and people with serious or complex medical conditions.
In June, the Centers for Medicare and Medicaid Services issued guidance requiring people in those groups to show that their conditions also “significantly impair” their ability to meet the work rules. The rule would have required chronically ill Medicaid recipients to prove they were medically frail before receiving a work exemption.
Stearns found that the states lacked sufficient time and resources to rebuild their eligibility-verification systems for the narrower standard. “The states have met their burden of showing irreparable harm for which monetary damages would provide inadequate compensation – they face the burden of costly and intensive alterations to their eligibility verification systems,” he wrote.
The judge also found that applying the guidance as written would cause “irreparable harm.” He wrote that “enforcement of an unlawful definition of medically frail may lead to the disenrollment of otherwise eligible vulnerable individuals relying on Medicaid coverage for continuity of care.”
“There is an inherent public interest in ensuring that the government follows the law,” Stearns said.
The court ordered states to wait at least six months after the work rules take effect before cancelling the health insurance of anyone who claims a medical exemption. During that period, medical-frailty exemptions will follow the definition set out in the law rather than the administration’s narrower interpretation.
The ruling applies only to the medical-frailty provision. The wider Medicaid work requirements remain in place and are due to be enforced nationally beginning in January. The decision adds uncertainty to the imminent national rollout of those requirements.
Stearns upheld two other parts of the administration’s approach. He sided with the government on requiring states to reject evidence of medical frailty that is more than 12 months old. He also upheld a policy allowing states to decide whether to accept a patient’s own statement that they are too sick to work instead of proof during the first year the requirement applies.
Starting in 2028, Medicaid expansion enrollees nationwide may self-attest once. At their next renewal, they must show that their condition prevents them from working.
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