As states prepare to implement Medicaid work requirements by January 2027, most of the states subject to work requirements (42 states and the District of Columbia) are planning to adopt an optional hardship exception for Medicaid expansion enrollees and applicants living in counties with high unemployment rates. A new KFF analysis estimates the reach of the high unemployment exception:
- In the 39 states that are adopting or may adopt the hardship exception, about 1.4 million or 7.5% of Medicaid expansion enrollees live in one of the 133 counties that currently meet the high-unemployment criteria. Nine in 10 of those enrollees are concentrated in five states: California, Michigan, New Jersey, New York and Oregon. Among the 12 undecided states, a large share of Medicaid expansion enrollees (32,800) live in Arizona counties with high unemployment.
- Four states—Indiana, Iowa, Missouri, and Oklahoma—do not plan to adopt the exception. About 3,300 Medicaid expansion enrollees in Iowa and Missouri live in high-unemployment counties and could be exempt if the states decided to adopt the exception.
The analysis uses 12-month average county unemployment rates; however, soon-to-be released guidance from the Centers for Medicare and Medicaid Services (CMS) may require a different methodology.