Beginning in January, new federal work requirements will mandate that adults enrolled in Medicaid through the Affordable Care Act expansion engage in work, school, volunteering, or qualifying activities for at least 80 hours monthly to maintain coverage. The legislation includes federal exemptions designed to protect individuals facing hardship, including those who are hospitalized, require travel for medical care, or reside in areas with high unemployment or disaster-affected regions.
According to research by healthcare policy nonprofit KFF, certain states including Missouri and Iowa have declined to adopt available hardship exemptions for their residents despite having counties that would qualify. New York City has taken the opposite approach, recently implementing the high-unemployment exemption for the Bronx, which would affect approximately 200,000 residents otherwise subject to the requirements.
Experts attribute the reluctance to adopt exemptions partly to ideological considerations. Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, noted that state officials who support work requirements may believe such mandates should apply uniformly regardless of local economic conditions. Sarah H. Gordon, associate professor at Boston University School of Public Health, suggested that more conservative states typically favor linking health insurance to employment or community engagement, and that declining exemptions reflects political preferences. Administrative burden also represents a potential factor, as states utilizing exemptions must submit ongoing data to federal authorities and modify eligibility systems accordingly.
Advocacy groups have criticized these decisions. Joel Ferber, director of advocacy at Legal Services of Eastern Missouri, characterized Missouri’s position as counterintuitive, arguing that Medicaid participants would prefer completing hardship forms to losing coverage. Experts warn that implementation variations across states will create uneven outcomes, with some states working to minimize coverage losses while others proceed without such protections. Researchers have pointed to Arkansas as a cautionary example; after implementing work requirements in 2018, over 18,000 residents lost coverage by year’s end despite research finding no significant employment gains.
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