Conservative states forgo federal Medicaid hardship exemptions

New federal work requirements for Medicaid, effective January 1, 2026, mandate that ACA expansion enrollees complete 80 hours of work or qualifying activities monthly to maintain coverage. Federal exemptions exist for high-unemployment areas, a provision recently adopted for the Bronx by New York City to protect approximately 200,000 residents from these new mandates.

Research by the healthcare policy nonprofit KFF indicates that Missouri and Iowa are not utilizing the high-unemployment exemption, even though counties in both states meet the qualification criteria. Experts suggest that state officials in these jurisdictions may be declining the exemption due to ideological opposition to exceptions or concerns about the ongoing administrative burden of submitting data to CMS and modifying eligibility systems.

Sarah H Gordon, an associate professor at the Boston University School of Public Health, noted that states refusing the exemption tend to be politically conservative and favor linking health insurance to employment. Joel Ferber of Legal Services of Eastern Missouri criticized the state’s stance, arguing that it prioritizes bureaucratic avoidance over patient support, as most Medicaid participants would prefer filing a hardship form over losing their healthcare coverage.

Jacob Wallace, a professor at the Yale School of Public Health, warned that Medicaid work requirements historically do not increase employment but do increase administrative burdens that cause people to drop out of programs. The implementation of these rules is expected to cause millions of Americans to lose coverage, a trend observed in Arkansas after it introduced similar requirements in 2018.