Missouri and Iowa are among conservative states choosing not to adopt a federal Medicaid hardship exemption, a decision experts attribute to political factors and administrative burdens. The exemption is designed to help low-income residents keep coverage during hardships like high unemployment.
New Work Requirements and Exemptions
New federal work requirements for Medicaid, effective 1 January, mandate that adults enrolled through the Affordable Care Act (ACA) Medicaid expansion work, attend school, volunteer, or engage in another qualifying activity for at least 80 hours a month to maintain coverage.
The legislation also includes federal exemptions to protect low-income individuals when they are hospitalized, travel for medical care, or reside in areas affected by disasters or high unemployment. Recently, New York City adopted the high-unemployment exemption for the Bronx, where about 200,000 residents would otherwise face the new requirements.
States Opting Out
According to new research by the healthcare policy nonprofit KFF, states like Missouri and Iowa are not taking up this exemption for their residents, despite having counties that would qualify. The Guardian has contacted both state departments for comment.
Experts told the Guardian that states may avoid the exemption due to administrative burdens and political considerations. Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, cited ideological opposition: “If [state officials] are advocates of work requirements, they may feel like these work requirements should apply to everyone evenly and whether someone lives in a county with high unemployment or not really shouldn’t be a factor.”
She added that adopting the exemption requires ongoing data submission to CMS and system updates to exclude people based on county of residence, which could also be a factor.
Political and Practical Implications
Sarah H Gordon, associate professor at the Boston University School of Public Health, noted that states not taking up the exemption tend to be more politically conservative, aligning with the idea that health insurance should be tied to employment or community engagement. “Not taking up that exemption is partly political,” she said, describing a “patchwork of implementation” where some states minimize coverage losses while others do not.
Joel Ferber, director of advocacy at Legal Services of Eastern Missouri, called it “disappointing” that the state is not planning to use the exemptions, saying the stated reason of avoiding bureaucratic burdens “doesn’t make sense.” He argued that Medicaid participants would overwhelmingly choose to fill out a hardship form over losing healthcare.
The introduction of these requirements is expected to cause millions of Americans to lose coverage. In Arkansas, which introduced Medicaid work requirements in 2018, more than 18,000 people had lost coverage by the end of that year, with no significant increase in employment.
Jacob Wallace, associate professor at the Yale School of Public Health, called the new requirements “very concerning,” noting they historically do not encourage work but create administrative burdens that lead to people dropping off the program. He emphasized the broad concern about coverage loss and the risk of losing people due to paperwork challenges.
