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Some conservative states rejecting Medicaid hardship exemptions despite qualifying counties

Confirmed1 source · Oct 18, 2026

States like Missouri and Iowa are declining federal hardship exemptions for new Medicaid work requirements, with experts citing both ideological opposition to exemptions and administrative burden as likely factors.

Some conservative states rejecting Medicaid hardship exemptions despite qualifying counties
Image via The Guardian

What happened

Federal work requirements for Medicaid, set to take effect January 1, will require adults enrolled through the ACA expansion to work, attend school, volunteer, or engage in qualifying activities for at least 80 hours monthly to maintain coverage. The federal law includes hardship exemptions for people who are hospitalized, traveling for medical care, or living in areas with high unemployment or disasters. New York City has adopted the high-unemployment exemption for the Bronx, which qualifies approximately 200,000 residents. However, states including Missouri and Iowa have chosen not to adopt this exemption for their residents despite having counties that meet the high-unemployment threshold, according to research by the healthcare policy nonprofit KFF.

Context

The policy decision creates stakes for coverage retention among low-income populations in states that decline the exemptions. Experts attribute non-adoption to two factors: ideological commitment to uniform work requirements regardless of local economic conditions, and administrative costs associated with tracking and exempting residents by county. Historical precedent from Arkansas, which implemented work requirements in 2018, shows that more than 18,000 people lost coverage by year-end with no significant increase in employment. Public health researchers emphasize that administrative barriers and paperwork confusion tend to reduce coverage even among those technically eligible for exemptions, suggesting that declining to adopt exemptions will likely result in coverage losses. The variation in state adoption reflects broader ideological differences about whether health insurance should be tied to employment.

What's disputed

The relative weight of administrative burden versus political ideology in states' decisions is characterized differently by sources—some emphasize the burden claim as potentially pretextual, while experts point to both factors operating simultaneously.