Phil Galewitz, KFF Health News
Millions of Medicaid enrollees might have a manner out of the brand new federal work requirement — in the event that they stay in a county with excessive unemployment.
By January 2027, President Donald Trump’s far-reaching domestic policy law would require many grownup, nondisabled Medicaid enrollees in 42 states and Washington, D.C., to work or volunteer 80 hours a month or go to highschool.
But beneath the regulation, Medicaid enrollees in counties the place unemployment is no less than 8% or 1.5 occasions the nationwide unemployment price might be shielded from the work requirement, if their state applies for an exemption.
A new analysis by KFF reveals that exemption within the GOP’s work requirement might supply a reprieve to probably tens of millions of Americans caught in a tricky spot — needing to work to safe medical insurance however having hassle discovering a job.
The Congressional Budget Office projected the work requirement would apply to 18.5 million Medicaid enrollees, inflicting about 5.3 million to lose their authorities well being protection by 2034. CBO spokesperson Caitlin Emma confirmed to KFF Health News that analysts factored the unemployment price exemption into their projections. Only states that expanded Medicaid beneath the 2010 Affordable Care Act or a particular waiver should enact a piece requirement, beneath the federal regulation.
But how many individuals might be exempt is dependent upon how the Trump administration interprets the regulation, along with whether or not their states’ officers apply.
For instance, if Trump officers exempt individuals in counties the place the unemployment price has been above the regulation’s thresholds for any month over a 12-month interval, about 4.6 million Medicaid enrollees in 386 counties might qualify for an exemption right this moment based mostly on the most recent unemployment knowledge, in keeping with KFF, a well being info nonprofit that features KFF Health News.
That quantities to simply beneath 1 / 4 of all Medicaid enrollees topic to the work requirement.
Under that one-month threshold, “the impact could be fairly significant,” stated Jennifer Tolbert, a co-author of the evaluation and the deputy director of KFF’s Program on Medicaid and the Uninsured.
But, she stated, the Trump administration is extra more likely to undertake a stricter threshold based mostly on common unemployment over a 12-month interval. That would align with work necessities beneath the federal Supplemental Nutrition Assistance Program, the meals help generally referred to as meals stamps.
Only about 1.4 million Medicaid enrollees residing in 158 counties might be exempted beneath that normal, or about 7% of the full topic to work necessities, KFF discovered. That’s about 7% of enrollees who stay in growth states who would in any other case want to satisfy the brand new requirement.
Based on the 12-month standards, about 90% of Medicaid enrollees who might be exempted based mostly on excessive unemployment reside in 5 states, in keeping with KFF: California, New York, Michigan, Kentucky, and Ohio. California alone accounts for over half of those that might be exempted.
The unemployment price exemption is one among a number of carve-outs from the Medicaid work requirement within the GOP’s regulation. The regulation additionally exempts mother and father with kids beneath 14, people who find themselves disabled or frail, and those that are pregnant, incarcerated, or in a substance use dysfunction program, amongst others. The excessive unemployment provision is totally different than most as a result of it exempts individuals residing in complete counties.
Two high Republicans key to the invoice’s passage — House Speaker Mike Johnson and Sen. Mike Crapo, chair of the Senate Finance Committee — didn’t reply to requests for remark.
To qualify for the Medicaid exemption, states must apply to the federal authorities on behalf of people in eligible counties. And if a county earned an exemption, the federal government would decide how lengthy it applies.
Even if the federal authorities grants exemptions broadly, well being advocates concern some Republican-led states might balk at making use of for exemptions to be able to hold enrollment down, as they are saying has been the case with SNAP exemptions. As of 2023, 18 states didn’t have an exemption beneath the SNAP program, though a few of their residents may be eligible.
“It’s not a guarantee that people can rely on,” stated Emily Beauregard, government director of Kentucky Voices for Health, an advocacy group that intends to push for the broadest doable exemptions to assist individuals keep their protection. Eastern Kentucky has a number of counties with perennially excessive unemployment.
In advocating for Trump’s invoice, many Republicans in Washington argued that most individuals who gained Medicaid advantages beneath the Affordable Care Act needs to be working to get off of presidency help.
But as Georgia’s and Arkansas’ experiences have proven, Medicaid work necessities could be expensive for states to run and frustrating for enrollees to navigate. About 18,000 individuals in Arkansas, or almost 1 / 4 of the state’s adults who gained Medicaid protection by way of the ACA growth, misplaced protection when the state had a piece requirement in 2018 and 2019. A courtroom ended the state’s work requirement program.
Critics level out that most Medicaid enrollees already work or have a incapacity or caregiving tasks, and so they argue the reporting necessities merely function a bureaucratic hurdle to acquiring and conserving protection. Under the GOP regulation, enrollees’ work standing must be verified no less than twice a yr.
Most of the protection losses as a result of work necessities happen amongst individuals who work or ought to qualify for an exemption however nonetheless lose protection as a result of purple tape, research shows.
Not each state should implement a piece requirement beneath Trump’s regulation, solely those who selected to broaden Medicaid protection to extra low-income individuals by way of the ACA or a federal waiver. The ACA has offered a whole bunch of billions in federal {dollars} to assist states cowl everybody making as much as 138% of the federal poverty degree — $21,597 for a person in 2025.
Forty states and Washington, D.C., took up the growth. Georgia and Wisconsin partly expanded their Medicaid eligibility by getting a federal waiver, including them to the checklist of states topic to the work requirement. These two states weren’t included within the KFF evaluation due to an absence of county-level enrollment knowledge.
Jennifer Wagner, director of Medicaid eligibility and enrollment on the left-leaning Center on Budget and Policy Priorities, stated she is happy the regulation makes some exceptions for locations the place jobs are scarce. It might restrict how many individuals lose protection due to the work requirement, she stated.
Wagner stated SNAP’s unemployment price exemption has helped tens of millions of individuals keep away from shedding their meals help, however its impression additionally is dependent upon whether or not a state seeks the waiver.
She is worried the Trump administration might make it troublesome for counties to get exempted beneath the Medicaid regulation.
“I’m glad it’s in there as it will certainly help people, but it’s still a terrible bill,” she stated. “This will not really blunt the harm of the bill.”
KFF Health News is a nationwide newsroom that produces in-depth journalism about well being points and is likely one of the core working packages at KFF—an unbiased supply of well being coverage analysis, polling, and journalism. Learn extra about KFF.
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