Voters in seven states bucked their conservative leaders to expand Medicaid at the ballot box.
Now officials in six of them are deploying tactics to make the upcoming implementation of work requirements especially strict, which could dramatically reduce the number of people covered.
A survey of Medicaid officials in all of the states that expanded the program, released this week by the health care think tank KFF, found that a minority of states are eschewing measures most jurisdictions are using to keep people from falling off the rolls. These states, most of them run by conservative Republicans, are instead adding hurdles: requiring low-income patients to provide more documentation more frequently in order to stay enrolled, offering fewer exemptions, and starting enforcement far earlier than required by federal law.
States that used ballot initiatives to expand Medicaid under the Affordable Care Act to able-bodied adults slightly over the federal poverty line are overrepresented in that group.
“For every Massachusetts that is bending over backwards to try to make sure there are no barriers to getting onto the program, you've got your Nebraskas and other states that are going to take a very different approach to helping people get on the program and keep their coverage,” said Sara Rosenbaum, an emeritus professor of health law at George Washington University’s School of Public Health.
Since the Supreme Court’s 2012 ruling made Obamacare’s Medicaid expansion optional, the vast majority of states — roughly half of which voted for President Donald Trump in 2024 and half for Kamala Harris — have collectively extended coverage to tens of millions of previously ineligible low-income residents.
Ten states still have yet to fully expand, while seven did so only after voters forced a referendum on the issue: Idaho, Maine, Missouri, Nebraska, Oklahoma, South Dakota and Utah.
Despite the expansion’s popularity, many state and federal GOP officials have worked to hamper it ever since, by limiting eligibility, slashing funding for outreach, imposing “trigger” laws that would do away with the expansion should federal funding for it ever decrease, and — in 2025’s One Big Beautiful Bill Act — applying work requirements only to the expansion population.
Some conservatives argue that Medicaid was never intended to cover the population enrolled in the expansion — nondisabled adults without children whose income puts them just above the federal poverty line — and see that coverage as a threat to services for those in “traditional” Medicaid, including pregnant women, children, people with disabilities, and parents below the poverty line. Others say states can’t afford to keep funding the program at a time of severe budget crunches, although the federal government picks up 90 percent of the tab.
Starting in 2027 — or in a handful of places, months earlier — many states aim to save money and crack down on what they say is widespread fraud by dropping tens of thousands of people from their insurance rolls who fail to prove that they are either working, going to school, volunteering, or caring for a loved one at least 80 hours per month. The Urban Institute, a center-left think tank, estimates that between 3 and 7 million Medicaid expansion enrollees will lose coverage due to the work requirements alone, with millions more impacted by the other provisions in the GOP megabill.
Now, in six of the seven ballot measure expansion states, the advent of work requirements offers the biggest opportunity yet for politicians to chip away at a program they have long opposed. (The exception is Maine, which flipped politically after its ballot initiative passed in 2017, and now has a pro-Medicaid-expansion Democratic governor who is seeking a softer implementation of the work rules.)
Idaho, which expanded Medicaid by ballot initiative in 2018, is one of just two states along with Indiana that plans to make low-income residents prove they’ve been working, volunteering, studying or caregiving at least 80 hours a month for three months in order to apply to Medicaid — more than the one month “look-back” required by Congress.
Oklahoma and Missouri, which both expanded Medicaid by ballot initiative in 2020, are two of just four states, along with Indiana and Iowa, that will not grant exemptions to people living in counties with high rates of unemployment. Oklahoma is also one of three, along with Indiana and Iowa, to not exempt residents of areas where there was a natural disaster.
Oklahoma and Missouri are also among a tiny minority of states that plan to outsource some enforcement tasks to artificial intelligence, a choice other state Medicaid officials told KFF they are worried will lead to errors.
“Focus group participants said they were eager for tools to assist with implementation, but they expressed reservations about adopting untested products,” Jennifer Tolbert, KFF’s deputy director of the Program on Medicaid and the Uninsured, told reporters on a Thursday call. “They noted that, if adopted, these tools might not function as intended, or may take too many resources.”
Nebraska and Utah, where voters approved expansion in 2018, and South Dakota, which passed a ballot measure in 2022, are not planning to hire any new staff, bring on contractors, or borrow workers from other agencies to manage the implementation.
Nebraska also started enforcement of the new rules this Friday, eight months earlier than the federal deadline.
Nebraska’s Medicaid director Drew Gonshorowski told POLITICO that the state is confident its existing staff can handle the early enforcement.
“In Nebraska, compared to a lot of states, our enrollment and eligibility system is a state-owned system, so we're just able to sort of deploy and implement work requirements uniquely more quickly than other states,” he said. “We really do believe that this is a great opportunity.”
Officials in the other five states did not respond to questions about their implementation choices.
Ballot initiative expansion states have “ranted and raved for years now about the undeserving poor,” said Rosenbaum. “But when you look at the 55-year-old farmers, the hourly workers, and other people who are going to lose their coverage, they’re going to see that they are not, as they insisted over and over again, all 24-year-olds playing video games.”
The ballot measure states and a handful of others are opting for the strictest version of the rules with the fewest exemptions, which the Urban Institute projects will trigger a purge of between 37 and 68 percent of Medicaid enrollees.
Most states are trying to soften the blow. Twenty nine states, for example, are exempting people facing various financial and medical hardships from the work requirements, while 36 states are requiring people to provide just one month of work records when they apply for Medicaid or renew it.
But even states that are trying to protect as many people as possible could see a lot of people fall through the cracks — with Urban Institute estimating 18 to 33 percent losing insurance.
“There are meaningful state choices that can be made that will mitigate coverage losses, but no state is going to be able to fully protect people's coverage. It's just not possible,” said Hannah Katch, a former senior adviser for the federal Centers for Medicare and Medicaid Services under President Joe Biden and former leader of California’s Medicaid program. “This policy was designed to cut eligible people off of Medicaid. That's why Congress used it as a pay-for for tax cuts: because it reduces federal expenditures on Medicaid.”
Katch and other experts are most worried about Nebraska, which is starting enforcement of the rules on Friday for the roughly 70,000 people enrolled in its Medicaid expansion.
The state rolled out a media campaign to make people aware of the rules less than a month before their launch, and just days before the start date, officials released a nearly 300-page document listing all of the medical diagnosis codes that would qualify someone for an exemption from the rules — something hospitals in the state had been requesting for months.
“This is just bad policy,” said Sarah Maresh, the program director for health care access at the nonprofit Nebraska Appleseed. “A vast majority of Nebraskans are working or would count as an exemption, but it is the red tape that causes the problems and really causes people to lose coverage. People don't know what's coming, and they don't know it applies to them, and they're just, frankly, unable to understand this really complicated system.”
KFF’s survey found, however, that even states that are waiting until the January deadline to implement the rules are worried about people getting lost in the shuffle. Issues Medicaid officials raised in this week’s report include the difficulty of doing outreach to the thousands of Medicaid expansion enrollees who are homeless and don’t have a fixed address, access to email, or a steady medical provider. They also highlighted the challenge of determining whether someone enrolling in Medicaid for the first time, who doesn’t have a documented medical history, has a condition that exempts them from the rules.
“What keeps me up at night is that this is too much too soon,” said Tricia Brooks, a research professor at Georgetown University’s Center for Children and Families. “An 18 month timeline for implementation of this kind of a major policy leaves states in the lurch.”
