Medicaid hardship exemption: Missouri and Iowa decline rule that could spare residents from work requirements
New federal Medicaid work requirements begin on 1 January, but Missouri and Iowa are not adopting the Medicaid hardship exemption for high-unemployment counties even though counties there would qualify, according to KFF research.
Medicaid hardship exemption: Missouri and Iowa decline rule that could spare residents from work requirements
Missouri and Iowa are choosing not to adopt the Medicaid hardship exemption for residents of high-unemployment counties, even though both states have counties that would qualify, according to new research by the healthcare policy nonprofit KFF. The decision matters because new federal Medicaid work requirements take effect on 1 January for adults enrolled through the ACA Medicaid expansion.
What the work requirements demand
Under the federal rules, adults covered through the ACA Medicaid expansion must work, attend school, volunteer or take part in another qualifying activity for at least 80 hours a month to keep their coverage starting on 1 January.
The federal law also builds in exemptions designed to help low-income people keep their Medicaid coverage when they are hospitalized, have to travel for medical care, or live in areas struck by disasters or high unemployment.
Some places are using the high-unemployment exemption. New York City has adopted it for the Bronx, sparing roughly 200,000 residents who would otherwise have been subject to the requirements.
Why Missouri and Iowa are holding out
Jennifer Tolbert, deputy director of KFF's Program on Medicaid and the Uninsured, pointed to ideological reasons a state might refuse the exemption.
"If [state officials] are advocates of work requirements, they may feel like these work requirements should apply to everyone evenly"
Tolbert also flagged the administrative side. If a state were to adopt this hardship exception, it would have to submit data on an ongoing basis to CMS and change its eligibility system so people could be exempted by county.
Sarah H Gordon, an associate professor at Boston University School of Public Health, observed that states not taking up the hardship exemption tend to be more politically conservative states, which view insurance as tied to employment.
In Missouri, the decision drew criticism from Joel Ferber, director of advocacy at Legal Services of Eastern Missouri, who called the state's choice not to take up the exemptions "disappointing". He said officials cite avoiding bureaucratic burdens for participants, but argued that Medicaid participants would overwhelmingly choose to fill out a hardship form over losing healthcare - in his words, "100% of them would likely choose to fill out the form".
Coverage losses to expect
Gordon described implementation as a patchwork: some states are moving early on work requirements while others try to minimize coverage losses, and she warned that "way more people will lose coverage" as states implement at different speeds.
Researchers who have studied earlier versions of the policy see grounds for concern. Arkansas introduced Medicaid work requirements in 2018; by the end of that year, more than 18,000 people had lost coverage, yet researchers found no significant increase in employment.
Jacob Wallace, an associate professor at the Yale School of Public Health, called the new requirements "very concerning".
"they don't encourage people to work, but they do seem to generate administrative burdens and paperwork"
Wallace warned that the more hoops people must jump through to qualify or exempt themselves, the more people lose coverage over paperwork problems - such as a state not having the right address or phone number for someone.
The requirements take effect on 1 January. Missouri and Iowa currently plan not to take up the exemption, and Gordon expects more people to lose coverage as states implement the policy at different speeds.
