On January 1, Trump's budget bill starts requiring most adults covered through Medicaid expansion to work, go to school or volunteer 80 hours a month to get or keep their health coverage.

The law also gives states a few safety valves. A state can pause the rule for people in a county hit by a disaster or a jump in unemployment. It can pause it for someone who just spent time in the hospital, or who has to travel a long way for medical care.

Missouri, Iowa and Indiana are the only three states turning down all four of those exceptions, the Missouri Independent reported on November 10.

What the exceptions are for

Here's what one of them looks like in real life. In January, a Tyson Foods meatpacking plant in Nebraska closed and about 3,000 jobs disappeared. Nebraska, which started enforcing work requirements early, secured a temporary reprieve from them for people in the surrounding county, where unemployment had surged.

Under the law, states can choose these short-term hardship exceptions:

• High unemployment. Counties with unemployment at or above 8%, or 1.5 times the national average.
• Disasters. Areas under a federally declared emergency or disaster.
• Hospital stays. People getting inpatient or acute care in a hospital, nursing home, or care facility.
• Medical travel. People who have to travel a long way for their own treatment or a dependent's.

Six of the eight states that border Missouri, including Oklahoma, Arkansas, Tennessee and Kentucky, plan to offer them. Missouri, Iowa and Indiana won't.

Missouri's answer: "Unemployment rates will not be a consideration"

Missouri's Department of Social Services had first signaled it would adopt some of the exceptions. Last month, it changed course. The department's spokesperson told the Independent that "unemployment rates will not be a consideration" for whether people have to meet the work requirement.

The state says it can cover people with serious medical problems through the exemptions the law already requires, for people who are "medically frail" and for caregivers. National experts say that leaves people out. Jennifer Wagner of the Center on Budget and Policy Priorities pointed to someone hospitalized with a broken ankle or a bad case of the flu: "a very acute but short-term condition" that "certainly would not leave you medically frail." The medically frail exemption, she said, "is not built to capture a sprained ankle."

And none of the required exemptions protect people because of where they live, even when a flood or a plant closing wrecks the local economy.

That isn't a theoretical risk in Missouri. The state had three federally declared disasters in 2026 alone: storms, tornadoes and flooding in 10 counties in April, in 34 counties in June, and in 9 counties in July.

If Missouri changes its mind after the next disaster, it would have to amend its Medicaid plan with the federal government first. KFF's Jennifer Tolbert said that could keep the state from responding quickly to an emergency.

"I'm curious what the pressure will be when there is a disaster, when there is a major plant closure in a rural area," Wagner said, "where the state clearly had an opportunity to protect those individuals and chose not to."

The Republicans who wrote the rule into law

The states made this choice. But the work requirement only exists because Congress passed it.

On July 3, 2025, the House gave final approval to Trump's budget bill. Every one of these 15 Republicans voted for it:

• Missouri: Ann Wagner, Bob Onder, Eric Burlison, Jason Smith, Mark Alford
• Iowa: Ashley Hinson, Mariannette Miller-Meeks, Zach Nunn
• Indiana: Erin Houchin, Jefferson Shreve, Jim Baird, Mark Messmer, Marlin Stutzman, Rudy Yakym, Victoria Spartz

The other two House Republicans from those states, Missouri's Sam Graves and Iowa's Randy Feenstra, voted for it too.

Their own states have now decided to enforce it as strictly as the law allows.

We've seen what that looks like. Nebraska's governor rushed to make his state the first with work requirements, and more than 1,000 people lost or were denied coverage in four months, mostly over paperwork. Ashley Hinson defended the rule by saying people on a taxpayer benefit should be working, when 92% of adults on Medicaid already work or have a reason they can't.

The bottom line

Trump's budget bill lets states pause Medicaid work requirements after a disaster, a spike in unemployment, a hospital stay, or a long trip for medical care. Missouri, Iowa and Indiana are the only three states turning down all four, even though Missouri had three federally declared disasters this year. All 15 House Republicans on this site from those three states voted for the law that created the work requirement.

Source

• Missouri among three states declining hardship exceptions to Medicaid work requirements — Missouri Independent, November 10, 2026
• Roll Call 190, H.R. 1 — Clerk of the U.S. House, July 3, 2025