Medicaid Work Requirements: Why Some States Skip Hardship Exemptions 2026

Medicaid work requirements are set to take effect on January 1, but some conservative states are choosing not to implement federal hardship exemptions—a decision experts say may be driven by political considerations. The new rules require adults enrolled through the Affordable Care Act’s Medicaid expansion to work, attend school, volunteer, or participate in another qualifying activity for at least 80 hours per month to maintain coverage.

The bill includes federal exemptions designed to protect low-income people who are hospitalized, must travel for medical care, or live in areas with disasters or high unemployment. Yet states like Missouri and Iowa are opting out of the high-unemployment exemption, according to research by the healthcare policy nonprofit KFF, even though they have counties that would qualify.

What the Medicaid Work Requirements Actually Say

The work requirements apply specifically to adults covered through the ACA’s Medicaid expansion, which many conservative states have already resisted. To keep coverage, enrollees must document at least 80 hours per month of work, school, volunteering, or other qualifying activities.

Federal law also provides exemptions for certain circumstances. These include being hospitalized, needing to travel for medical care, or living in an area affected by a disaster or high unemployment. The exemptions are optional for states—meaning state officials can decide whether to apply them.

Which States Are Skipping the Exemptions?

Missouri and Iowa have chosen not to adopt the high-unemployment exemption, per KFF’s findings. Both states have counties that would meet the criteria for the exemption, yet officials have declined to implement it.

By contrast, New York City recently adopted the high-unemployment exemption for the Bronx, where about 200,000 residents would otherwise have faced the new requirements. The Guardian contacted Missouri and Iowa state departments for comment but did not receive an immediate response.

Why States Might Refuse Federal Help

Experts point to several reasons why a state might forgo the exemptions. One is administrative burden: implementing exemptions requires additional paperwork and processing, which can strain state resources.

But political factors also play a role. Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, suggested that some states may be reluctant to appear flexible on Medicaid expansion. “There may be political reasons,” she told the Guardian, noting that some officials oppose the expansion itself and may not want to make it easier to maintain coverage.

The Real-World Impact on Low-Income Residents

Without the high-unemployment exemption, residents in qualifying counties must meet the work requirements or risk losing coverage. In areas with limited job opportunities, that could mean thousands of people lose access to care. The longer history behind the story is traced in Medicaid Work Requirements: Why Some States Skip Hardship Exemptions.

The exemptions were designed to prevent exactly this scenario. By declining to use them, states may increase the number of uninsured residents and shift costs to hospitals and emergency rooms. The background to this story is set out in Care Workers May Get Exemptions from UK Immigration Rules. A related thread runs through Care Workers Exempt from UK’s Tough Immigration Rules?. Earlier coverage in Care Workers May Get Exemption from UK Immigration Rules shows how the argument developed.

Key Takeaways for Medicaid Enrollees and Advocates

• Work requirements start January 1 for ACA Medicaid expansion adults in affected states.
• Federal hardship exemptions exist but are optional for states to implement.
• Missouri and Iowa have declined the high-unemployment exemption despite qualifying counties.
• New York City adopted the exemption for the Bronx, protecting 200,000 residents.
• Political and administrative reasons drive state decisions, experts say.

Comparison of State Approaches to Medicaid Exemptions

What to Watch Next

As the January 1 deadline approaches, advocacy groups are likely to challenge state decisions. Legal action could force some states to implement exemptions, especially where federal guidance suggests they should. A closer look at the same subject appears in UK Care Workers Could Get Exemption from Tough Immigration Rules. Anyone following the wider picture can start with Finance: latest articles. The same theme surfaces in UK Bank Tax: Why Too Big to Fail Must Mean Too Big to Tax, which takes a different angle.

Enrollees in Missouri, Iowa, and other states should check with local Medicaid offices to understand their obligations and whether they qualify for any exemptions. Understanding the rules is the first step to maintaining coverage. Context on how this played out before sits in AI Medical Debt Collection: How Artificial Intelligence Will Reshape. A companion piece, Trump Immigrant Purge Could Cut Social Security by $2,000 a Year, approaches the same subject from another angle.