All 41 states that expanded Medicaid eligibility under the Affordable Care Act will see fewer people covered due to new federal work requirements and more frequent eligibility checks. But the percentage of recipients who lose coverage will vary greatly from state to state, depending on how state officials implement the new rules, according to a new report.

The report, released this week by the Urban Institute with support from the Robert Wood Johnson Foundation, projects that in 2028, between 4.9 million and 10.1 million people will lose coverage as a result of the federal policy changes included in the broad tax and spending measure President Donald Trump signed last summer. That prediction is roughly in line with estimates by the Congressional Budget Office, which projected last fall that the changes would increase the number of people without health insurance by 7.5 million in 2034.

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Whether the actual number ends up at the low end or the high end of that estimate will depend on state policy, according to the researchers. States that automatically check eligibility using data-matching, impose the minimum work requirements allowed under federal law and broadly define certain exemptions, such as those for “medical frailty,” will minimize the number of people who lose coverage.

On the other end of the spectrum, states that require stricter documentation of work hours and implement narrower exemptions will see more people dropped from the rolls.

With stricter state policies, the report projected that eight states — Connecticut, Massachusetts, Maryland, Minnesota, Missouri, New York, Vermont and Wisconsin — would see a decline in enrollment of 60 percent or more. (Wisconsin hasn’t expanded Medicaid under the ACA, but it was included in the study because it received a federal waiver that makes some of its Medicaid enrollees subject to work requirements.)

Arkansas, Idaho, Montana, North Dakota, Nebraska, New Mexico, Oklahoma and Oregon would have the smallest declines under strict policies, but would still see losses ranging from 37 percent to 46 percent.

With the least stringent policies, North Dakota and South Dakota would have the smallest declines — 18 percent and 19 percent, respectively. Even under lax rules, six states — Connecticut, Massachusetts, Maryland, New York, Virginia, Vermont —- would see declines of 30 percent or more.

Nationwide, between 19 percent and 37 percent of people who already work will lose Medicaid coverage, according to the analysis, due to challenges such as fulfilling the documentation requirements to prove that they work.

States have to enforce work requirements by next January. They may enforce them earlier via a waiver or state plan amendment, but so far only one state, Nebraska, has announced a plan to implement the requirements earlier, in May.

Some groups are exempt from the work requirements, including American Indian and Alaska Natives, people deemed “medically frail,” households receiving benefits through the Supplemental Nutrition Assistance Program, caretakers for children under age 13 or for those with disabilities, foster care youth and former foster care youth under age 26, among others.