How Will New Federal Requirements Affect Medicaid Expansion Enrollees in the Fourth District?

Expansion Enrollment and Outcomes in the Fourth District

As of December 2024, Medicaid expansion enrollment rates in Fourth District states for residents aged 18 to 64 ranged from 10.2 percent in Ohio to 17.3 percent in Kentucky (Table 1).² Enrollment rates in West Virginia and Kentucky ranked in the top 10 among all 41 expansion states, and both states had an enrollment rate that was greater than 1.5 times the national rate. Because Medicaid eligibility is closely tied to income, regions with larger shares of low-income households, including the portions of Kentucky and West Virginia that lie in the Fourth District, tend to have greater overall Medicaid enrollment rates.

Table 1. Percentage of Population Aged 18 to 64 Enrolled in Medicaid Expansion (by State)

Sources: Medicaid Budget and Expenditure System (MBES), Census Bureau, and author’s calculations
Last data point: December 2024 for Medicaid expansion enrollment, 2024 for state populations.

One straightforward measure of the expansion’s impact on eligible individuals is the change in uninsured rates for this population since before the program took effect in 2014. Table 2 shows this change in the Fourth District, its metro areas and nonmetro counties, and the nation from 2013 through 2023. Among all expansion-eligible individuals in the Fourth District, the uninsured rate fell from 31.8 percent in 2013 to 13.5 percent in 2023, a decline of 18.3 percentage points. The national decline of 18.7 percentage points slightly exceeded that of the Fourth District, though the overall uninsured rate among the expansion’s target population remained higher nationwide, largely because of the elevated rates in nonexpansion states (although the creation of the ACA marketplace, a federally run online health insurance exchange, resulted in a decline in uninsured rates in nonexpansion states, this decrease was not as pronounced as in expansion states). Notably, in the Fourth District, metro areas at least partially contained within West Virginia or Kentucky experienced the greatest declines in the uninsured rate for eligible individuals.

Table 2. Change in Uninsured Rates Among Medicaid Expansion-Eligible Individuals

Sources: Census Bureau Small Area Health Insurance Estimates and author’s calculations
Notes: Includes individuals aged 18 to 64 with income at or below 138 percent of the federal poverty level. The nonexpansion states are Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. The Cincinnati and Huntington–Ashland metro areas include counties that are not part of the Fourth District.

Alongside these changes in uninsured rates, qualitative reports can provide insight about how conditions have changed for expansion enrollees since the policy took effect. In Ohio, which is home to a majority of Fourth District residents, assessments conducted by the state in 2016 and 2018 found that expansion enrollees had better access to physical and mental healthcare, higher healthcare utilization rates, and fewer emergency department visits. These enrollees also felt more secure in their employment, found it easier to seek new employment, and reported improved overall financial stability. The same reports determined that 75 percent of Ohio expansion enrollees had no insurance coverage prior to enrolling in Medicaid, while the remaining 25 percent either found employer-based insurance too costly or lost their employer-based coverage prior to enrolling in Medicaid.³ Research about the broader population of expansion enrollees in the United States is generally consistent with the above reports and has also found that the Medicaid expansion led to reduced mortality rates among low-income adults.

Impacts of Past Work Requirements

By linking individuals’ Medicaid eligibility with their employment status, work requirements are meant to reduce individuals’ reliance on Medicaid by improving their financial stability. To date, only Arkansas has tested a work requirement policy for existing Medicaid expansion enrollees.^4,5 However, the federal government’s Supplemental Nutrition Assistance Program (SNAP) has a longstanding work requirement that has been studied extensively.

Research is mixed regarding the impact of the SNAP work requirement policy on employment. Some research suggests that it does little to increase labor supply or employment, while other research finds that the policy does modestly boost employment. However, studies consistently suggest that SNAP participation is meaningfully lower among individuals who are subject to the work requirement policy. Analyses of the Medicaid work requirement program in Arkansas find no evidence that enrollees in that program were more likely to be employed but conclude that they were less likely to have Medicaid or other insurance compared to similar individuals in other states who were not subject to work requirements.⁶ Research also suggests that enrollees who were subject to the Arkansas policy frequently struggled with procedural issues, and this caused many individuals who were otherwise eligible for Medicaid to be disenrolled. Of the roughly 18,000 individuals who lost Medicaid coverage after Arkansas implemented its work requirement, many later reported problems paying medical debt or said they had delayed taking medications because of cost.

How Does the New Community Engagement Requirement Work?

Beginning in January 2027, able-bodied, working-age adults will be required each month to work or participate in a work program for no fewer than 80 hours, complete at least 80 hours of community service, enroll in an educational program at least half time, or perform some combination of these activities for no fewer than 80 hours to remain eligible for coverage through the Medicaid expansion. Individuals’ eligibility will be evaluated when they apply to receive or renew coverage. While many states, including all the Fourth District states, currently set these redetermination intervals at one year, the new policy requires states to verify each enrollee’s eligibility every six months; redeterminations more frequent than this are permitted under the law. Individuals who are found to be compliant using data readily available to states will maintain their Medicaid coverage, while those who are not obviously compliant will have 30 days to prove their eligibility before being disenrolled.

Individuals who do not meet the above requirements can qualify for or maintain insurance through the Medicaid expansion if they meet one of several other criteria. States must make exceptions for parents, guardians, and caretakers of children under the age of 14 or of disabled individuals; pregnant women; foster youth under age 26; the “medically frail” (including disabled individuals and those undergoing treatment for substance use disorder); American Indians and Alaska Natives; disabled veterans; or anyone entitled to Medicare or already compliant with the SNAP work requirement. In addition, states can invoke a set of optional “hardship” exemptions on a case-by-case basis. These optional exemptions include recent hospital stays, poor geographic access to healthcare, a high unemployment rate in an individual’s home county, and national emergencies.⁷ Despite this long list of exemptions, tighter redetermination intervals, a larger target population, and short windows for individuals to prove eligibility make the new federal requirement more stringent than many similar policies enacted in the past.

Who Will Be Affected in the Fourth District?

Figure 1 shows the 2023 work status of Medicaid recipients in the Fourth District states who likely would have been subject to the new community engagement requirement had it been in place that year. While 73 percent (the sum of the green bars) reported working that year, only 67 percent reported working enough hours to comply with the new requirement.^8,9 Those who reported not working for the entire year provided various reasons why this was the case. Individuals most often reported not working because of caregiving responsibilities (12 percent), while a smaller share (7 percent) cited school attendance. Most of the individuals who reported not working at all in the prior year would not have been counted in the labor force, as they also did not report looking for work at any time during the year leading up to the survey.¹⁰ Although the respondents who worked enough hours would have had the clearest path to maintaining their Medicaid coverage under the new requirement, the roughly one-third who worked too few hours or reported not working for various reasons could have been exempt from the requirement depending on their specific life circumstances. Still, a notable number could be at risk of going uninsured if they do not secure exemptions from the new federal requirement or work more hours, especially if states face challenges identifying individuals who qualify for an exemption.

As of the writing of this report, Pennsylvania’s Department of Human Services estimates that 310,000 enrollees in the state will lose access to Medicaid because of the community engagement requirement and other changes brought on by recent legislation.¹¹ The state governments in Kentucky, Ohio, and West Virginia have not published corresponding figures. However, an analysis by the Kaiser Family Foundation (KFF) estimates that many individuals will also lose Medicaid coverage in Kentucky (200,000), Ohio (290,000), and West Virginia (54,000). As a result of new, stricter eligibility standards for cost-sharing in the ACA Marketplace, which is often the next-best option for individuals who lose their Medicaid coverage, it is possible that employer-based insurance will become the only viable option for individuals who are disenrolled from Medicaid because of the new requirements.

Conclusion

The Medicaid expansion has led to large decreases in the uninsured rate of eligible adults in the Fourth District and across the United States. In the time since the expansion took effect, surveys and other research have shown that eligible individuals in the Fourth District and elsewhere have experienced improved health, employment, and financial outcomes because of the expansion. As of 2023, only about two-thirds of select Medicaid enrollees in Fourth District states reported working enough hours that they would have been able to qualify for or maintain Medicaid coverage if the new federal requirements had been in place during that year. Individuals who are not working enough hours could be at risk of going uninsured if they are unable to increase their working hours or do not secure exemptions from the new federal requirements.

Table A1. Medicaid Expansion Enrollment as a Percentage of Metro Populations Aged 18 to 64

Sources: Ohio Department of Medicaid, Pennsylvania Department of Human Services, Census Bureau Small Area Health Insurance Estimates, and author’s calculations
Last data points: July 2025 for Pennsylvania, June 2025 for Ohio, 2023 for population.
Notes: These figures are the sums of county data. Medicaid expansion enrollment data are not available for counties in West Virginia or Kentucky. Pennsylvania nonmetro counties include only those that lie in the Fourth District.