The Trump administration's CMS rules, effective January 2026, require non-exempt adults aged 19-64 to document 80 hours monthly of work, community service, or half-time schooling, projecting $326 billion in federal savings but 5.3 million coverage losses per STAT analysis of the 2025 tax legislation. This extends beyond the original reporting by exposing how exemptions for 'medically frail' individuals—explicitly excluding conditions like diabetes, asthma, and ADHD—clash with real-world clinical realities where these comorbidities often impair sustained employment. An observational study of Arkansas's 2018 waiver (Sommers et al., New England Journal of Medicine, 2019; n=~5,000 low-income adults, pre-post design without randomization) found uninsured rates rose 7 percentage points with negligible employment gains, highlighting administrative burdens that disproportionately affected those with chronic conditions. A follow-up Health Affairs analysis (2019, observational claims data from 3 states) confirmed similar patterns, noting conflicts of interest absent but limited by state-level policy variation. These findings reveal what mainstream coverage glosses over: self-attestation until 2028 offers temporary relief, yet subsequent one-year-old documentation mandates ignore adjudication delays averaging 6+ months, per Harvard's McIntyre. Tensions between mandates and barriers—such as transportation, childcare, or fluctuating health—suggest the HHS poverty-reduction brief (projecting 1.6-2.9 million fewer poor) overstates benefits while underestimating care disruptions for working-poor adults already employed at rates above 60% per KFF data.