How complexity becomes a tool to reduce enrollment while avoiding political accountability
When the Congressional Budget Office estimated that 11.8 million people would lose health coverage by 2034 under the One Big Beautiful Bill Act signed into law on July 4, 2025, the numbers told only part of the story. What the CBO’s analysis reveals—and what disabled people have experienced for decades—is that paperwork complexity isn’t an unavoidable bureaucratic reality. It’s a deliberate policy mechanism designed to reduce enrollment without the political cost of openly cutting benefits.
This is a story about how governments redistribute costs away from their budgets and onto disabled people’s time, energy, and bodies—then call it “program integrity.”
What Administrative Burden Actually Means
Administrative burden is the constellation of obstacles governments place between people and the benefits they’re legally entitled to receive. It includes:
- The paperwork itself—forms that request the same information multiple times, documentation requirements that assume stable housing and reliable mail service, questions written at reading levels inaccessible to many
- The frequency of verification—requiring people to re-prove their poverty every six months, or in some states’ proposals, every month
- The mechanisms of verification—phone systems with multi-hour wait times, websites that crash under load, offices with limited hours in locations difficult to reach without a car
- The consequences of any gap—automatic termination of coverage, requirements to reapply from scratch, months-long processing times to restore benefits
When Louisiana implemented quarterly income checks for adult Medicaid enrollees in 2024, failure to respond to requests for information was the single largest reason for coverage terminations, comprising about two-thirds of closures across three verification cycles. These weren’t people who became ineligible. They were people who didn’t receive the letter, couldn’t navigate the verification process, or couldn’t respond within the required timeframe.
The policy worked exactly as designed.
How the One Big Beautiful Bill Act Weaponizes Paperwork
The Medicaid provisions in the One Big Beautiful Bill Act demonstrate administrative burden operating at scale. The CBO projects that work requirements will account for $326 billion in federal Medicaid savings over ten years—the largest share of the estimated $911 billion in total Medicaid cuts in the law. Those “savings” come almost entirely from coverage losses, not from reduced eligibility.
The work requirement provisions require disabled people and other Medicaid enrollees to complete 80 hours per month of approved activities and, critically, to document and verify that completion every six months. States must implement systems to track compliance, process exemptions, and terminate coverage for anyone who doesn’t successfully navigate the verification process.
The CBO estimates that by 2034, 18.5 million people will be subject to work requirements annually, federal Medicaid coverage will decrease by an estimated 5.2 million adults, and work requirements will ultimately increase the number of people without health insurance by 4.8 million. The CBO found that work requirements would have no meaningful impact on employment rates, citing research from Arkansas showing that “many participants were unaware of the work requirement or found it too onerous to demonstrate compliance,” resulting in coverage loss.
This is administrative burden distilled to its purest form: a requirement that doesn’t achieve its stated goal of increasing employment but does achieve its unstated goal of reducing enrollment.
The law also mandates that 700,000 people will lose Medicaid and become uninsured in 2034 due to new requirements that expansion enrollees re-prove their eligibility every six months instead of annually. These aren’t people who become ineligible mid-year. They’re people who will fail to navigate the paperwork twice as often.
The Evidence From Unwinding: When Paperwork Is the Policy
The Medicaid “unwinding” period from April 2023 through mid-2024 provided a natural experiment in how administrative burden operates. After three years of continuous enrollment during the COVID-19 public health emergency, states resumed eligibility redeterminations for approximately 95 million people. The results were stark: nearly 70% of individuals losing coverage were disenrolled for procedural reasons—meaning they lost coverage not because they were ineligible, but because of paperwork failures.
In Texas, the state implemented monthly income checks between 2009 and 2023 for children in Medicaid. When data sources reflected income above the Medicaid threshold, families received letters providing only 10 days from the date the system generates the letter to respond and prove eligibility. On average, over 6,000 households were contacted each month and 70% of children lost coverage, with the majority—over 4,000 children—disenrolled for procedural reasons each month. The data showed that over half the children who were disenrolled re-enrolled within 12 months, suggesting that they were inappropriately disenrolled for paperwork or administrative reasons.
The Government Accountability Office found that during unwinding, the Centers for Medicare & Medicaid Services found compliance issues with federal redetermination requirements in almost all states, including with long-standing requirements. In one documented case, over 400,000 eligible people lost coverage because states assessed household, not individual, eligibility.
These weren’t implementation failures. The systems worked exactly as they were designed to work: creating barriers that eligible people couldn’t overcome.
Why Simplification Is Treated as a Risk
Policy makers understand that administrative burden reduces enrollment. A 2025 study in Health Affairs found that technical interventions to automate Medicaid renewals in four states increased ex parte (automatic) renewals by 28 percentage points and decreased procedural denials by 9 percentage points. These weren’t complex changes—they involved using existing data sources more effectively and reducing documentation requirements.
Yet the One Big Beautiful Bill Act moves in the opposite direction, adding verification requirements and increasing the frequency of redeterminations. The law also increases Medicare costs for low-income beneficiaries by eliminating key improvements that streamline access to the Medicare Savings Programs. The CBO projects nearly 1.4 million low-income people with Medicare would lose their MSP coverage due to the rollback of these simplifications.
The pattern is clear: when simplification would increase enrollment, it’s treated as a budget risk to be prevented. When complexity reduces enrollment, it’s defended as necessary for “program integrity.”
This framing serves a political purpose. When a government openly cuts eligibility—changing income thresholds, eliminating covered services, or ending programs—the political accountability is clear. But when a government maintains formal eligibility while making benefits practically inaccessible through administrative barriers, the responsibility diffuses.
People who lose coverage are framed as non-compliant rather than excluded. States blame federal requirements; the federal government blames state implementation. The paperwork becomes a buffer between policy makers and the consequences of their choices.
The Redistribution of Costs
Administrative burden doesn’t eliminate the costs of determining eligibility—it redistributes them. Instead of states and the federal government bearing the administrative costs of verification, those costs fall on:
- Disabled people’s time: Hours spent on hold with state agencies, multiple trips to offices for in-person verification, repeated submission of the same documents when they’re lost in processing
- Disabled people’s money: Costs of obtaining documentation, transportation to offices, lost wages from time spent navigating the system, late fees when coverage gaps interrupt automatic payments for utilities or housing
- Disabled people’s health: Delayed care during coverage gaps, medications rationed or discontinued, conditions that worsen without treatment, the physiological stress of navigating hostile bureaucratic systems
For disabled people with limited energy, pain that fluctuates, or cognitive disabilities that affect executive function, these barriers aren’t mere inconveniences—they’re often insurmountable. A person who can work 20 hours a week may not have the capacity to also spend 10 hours on hold with the state Medicaid office. Someone who struggles with executive function may be fully capable of their job with accommodations but unable to navigate a multi-step verification process with strict deadlines.
The Government Accountability Office noted that during unwinding, many states struggled with outdated contact information, lack of education and awareness about redetermination requirements, and enrollees’ inability to handle the burden of paperwork. But these aren’t implementation problems to be solved—they’re features of a system designed to reduce enrollment through attrition.
What We Will Not Do
We will not offer tips for navigating administrative burden. We will not provide strategies for successful documentation. We will not explain how to request extensions or expedited processing.
Those resources exist and have their place. But treating paperwork as an individual problem to solve through better personal strategies obscures its function as a policy tool. The issue isn’t that disabled people need to get better at paperwork. The issue is that paperwork is being used to achieve policy goals that would be politically unacceptable if stated explicitly.
When the CBO estimated that the OBBBA will cut federal spending on Medicaid and Children’s Health Insurance Program benefits by $1.02 trillion, due in part to eliminating at least 10.5 million people from the programs by 2034, that’s not a prediction about people becoming wealthier or finding better insurance. It’s a prediction about how many people will fail to overcome administrative barriers.
Why This Matters Now
The One Big Beautiful Bill Act’s Medicaid provisions represent the largest rollback of federal support for health care in American history. But the mechanisms it uses—work requirements, frequent redeterminations, documentation burdens, restricted state flexibility to simplify enrollment—aren’t new. They’re the same tools that have been used for decades to limit access to benefits while maintaining the formal appearance of eligibility.
What’s different now is the scale and the explicitness of the goal. The CBO’s projections don’t hide that these policies will reduce coverage for people who remain formally eligible. The question is whether we’ll continue to treat that as an unfortunate side effect of necessary program integrity measures, or recognize it as the primary purpose of the policy design.
Research shows that when federal funding for Medicaid decreases, states tend to cut optional benefits such as home- and community-based services first. These are the services that allow disabled people to live in their communities rather than institutions—the services that make independent living possible.
The administrative burden provisions in the One Big Beautiful Bill Act will interact with these funding cuts in predictable ways: fewer people will successfully maintain enrollment, states will face budget pressure from lost federal matching funds, and the services disabled people depend on will be among the first cut.
This isn’t speculation. It’s the documented pattern from every previous round of Medicaid restrictions, now operating at unprecedented scale.
What Administrative Burden Really Is
Administrative burden is a policy choice that accomplishes through complexity what would be politically costly to accomplish through direct cuts. It’s a mechanism for reducing enrollment while diffusing accountability. It redistributes the costs of government programs from budgets onto people’s bodies and lives. And it operates most effectively against the people least able to overcome it—disabled people, poor people, people juggling multiple jobs, people without stable housing, people with limited English proficiency, people with cognitive disabilities.
The complexity isn’t accidental. The burden isn’t a side effect. The paperwork is the policy.
Learn More
Understanding Your Rights:
- Healthcare Rights - Know what you’re legally entitled to
- Medicaid (US) - How Medicaid works and what recent changes mean
- Benefit Denials and Appeals - What to do if you lose coverage
Systemic Context:
- Disability Models - How society’s frameworks shape policy
- Healthcare Navigation - Broader healthcare access challenges
- Advocacy and Self-Advocacy - Organizing for systemic change
For Policy Makers and Administrators:
- Healthcare Providers Toolkit - Understanding disabled people’s experiences with healthcare systems
- Public Safety Officers Toolkit - Disability awareness in crisis response
The Crip Chronicle is a publication of DisabilityWiki.org, centering disabled people’s expertise and grounded in disability justice principles. This article is informed by disabled-led organizing, policy research, and the documented experiences of disabled people navigating benefits systems.
Sources
Center on Budget and Policy Priorities. (2025). “By the Numbers: Harmful Republican Megabill Will Take Health Coverage Away From Millions of People and Raise Families’ Costs.” Available at: https://www.cbpp.org/research/health/by-the-numbers-harmful-republican-megabill-will-take-health-coverage-away-from
Congressional Budget Office. (2025). “Estimated Budgetary Effects of Public Law 119-21.” Available at: https://www.cbo.gov/publication/61570
Center for American Progress. (2025). “The Truth About the One Big Beautiful Bill Act’s Cuts to Medicaid and Medicare.” Available at: https://www.americanprogress.org/article/the-truth-about-the-one-big-beautiful-bill-acts-cuts-to-medicaid-and-medicare/
Kaiser Family Foundation. (2025). “A Closer Look at the Work Requirement Provisions in the 2025 Federal Budget Reconciliation Law.” Available at: https://www.kff.org/medicaid/a-closer-look-at-the-work-requirement-provisions-in-the-2025-federal-budget-reconciliation-law/
Georgetown University Center for Children and Families. (2025). “Thinking Frequent Medicaid Redeterminations Won’t Hurt Children’s Health Insurance? Take a look at What Happened in Texas.” Available at: https://ccf.georgetown.edu/2025/05/01/thinking-frequent-medicaid-redeterminations-wont-hurt-childrens-health-insurance-take-a-look-at-what-happened-in-texas/
U.S. Government Accountability Office. (2024). “Medicaid: Federal Oversight of State Eligibility Redeterminations Should Reflect Lessons Learned after COVID-19.” GAO-24-106883. Available at: https://www.gao.gov/products/gao-24-106883
Health Affairs. (2025). “Interventions To Automate Medicaid Renewals Reduce Procedural Denials And Increase Coverage.” Available at: https://www.healthaffairs.org/doi/10.1377/hlthaff.2025.00316
Medicare Rights Center. (2025). “Final House Vote on Devastating Health and Food Assistance Cuts.” Available at: https://www.medicarerights.org/medicare-watch/2025/07/03/final-house-vote-looms-on-devastating-health-and-food-assistance-cuts