Kevin Wehner has been there for Missourians as they have dealt with unanswered questions, long wait times and the confusion as they enrolled for government insurance.
He was there as the Affordable Care Act marketplace came online, and as Missouri slowly expanded its Medicaid program, known as MO HealthNet.
He’s witnessed Missouri struggling for years to process benefits applications in a timely manner.
Now, under President Donald Trump’s new budget plan, Americans aged 19 to 64 who are enrolled in Medicaid will be required to show proof of 80 hours of work, school, caregiving or volunteering a month to be eligible for coverage.
Wehner worries about what new Medicaid work requirements might mean for the people he assists on a day-to-day basis.
“It’s going to directly affect the Medicaid expansion (group),” said Wehner, a benefits enrollment counselor at Missouri Connections for Health in Columbia. “I think tangentially, it will affect the other populations, just because of the amount of resources that will be needed to see if these people are putting in 80 hours.”
For years, Missouri has struggled to process social services applications in a timely manner, drawing the ire of advocates and the courts. Federal regulations require states to process Medicaid applications based on income in 45 days, but Missouri has repeatedly violated the time frame requirements.
Wehner anticipates more confusion with the new rules, which are slated to begin in December 2026, after the midterm elections.
Research in states that have put work requirements in place confirms that suspicion. Enrollees found it difficult to fulfill the requirements and submit the proper documentation, leading to people losing coverage.
“I imagine I’m going to get a lot of people asking for help,” Wehner said. “You get your yellow letter in the mail. It’s several pages. Even when I’m working with people, I get a highlighter and I go through and find, ‘OK, here’s what we need to do.’ It’s not really obvious what you need to do.”
New estimates from KFF found that the Trump administration’s budget package would reduce federal Medicaid spending by $911 billion over the next 10 years and increase the number of uninsured Americans by 10 million. The largest portion of savings would come from work requirements on the Affordable Care Act expansion group – totaling about $326 billion saved over the next decade.
In Missouri, that would amount to an estimated 130,000 people losing access to Medicaid as their form of health insurance.
How the state may shift to handle increased eligibility checks
For years, Missouri has looked to update its technology to better handle the administrative burden as advocates demanded solutions to the delays across Medicaid and Supplemental Nutrition Assistance Program (SNAP) applications.
“It really is going to be a new system to implement,” said Lucas Caldwell-McMillan, the chief of policy at Empower Missouri, an anti-poverty advocacy group. “Right now we’ve got a pretty outdated system that is struggling. I think the frontline agency staff are working their hardest to implement it now, but they’re falling short.”
Under the new framework for Medicaid, states will need to process proof of the 80 hours of work, school, caregiving or volunteering, and will need to check eligibility for enrollment twice a year, rather than the current standard of once annually.
“These are six-month eligibility checks, so essentially doubling the work there,” said Caldwell-McMillan. “Both on the participant, but also the agency. And instituting these work requirements in Medicaid will require a whole new system to verify information that’s never been verified by the Medicaid agency before.”
According to Timothy McBride, a health economist and professor at the Washington University School of Public Health, states and enrollees have struggled to keep track of the documentation required to track whether people are working.
“The recipient has to actually interact with the program and make sure they get the paperwork filled out and submitted and it doesn’t get lost,” McBride said. “And that’s where it has broken down in states like Missouri, and where this has caused problems in our past.”
The increased burden for the state could come at a high cost, with not much savings. Research shows that both in Missouri and at the national level, about 90% of adults on Medicaid already have a job or would be considered exempt from work requirements.
States like Arkansas and Georgia have looked to put work requirements in place for years, but both have struggled.
Arkansas briefly put 20-hour per week work requirements in place from 2018 to 2019 for childless adults aged 30 to 49. After a federal court blocked the requirements, Arkansas stopped the program.
But in the brief time those requirements were in place, about 18,000 enrollees in the state lost their coverage. The state spent more than $26 million in administrative costs on eligibility checks and to put the program in place.
A study found that half of those in Arkansas who had lost Medicaid as part of the requirements reported serious problems paying off medical debt, while 56% delayed some form of medical care due to the cost and 64% delayed medication due to the cost.
The study also found that the work requirements did little to increase the number of enrollees who were employed. More than 95% of those in the work requirement group were either already working or qualified for an exemption. There did not appear to be any significant upticks in employment as a result of the requirements.
In 2023, 44% of the adults 19-64 enrolled in Medicaid were working full time, while 20% were working part time. Another 12% didn’t work due to caregiving, while 10% didn’t work due to illness and 7% didn’t work because they were enrolled in school, leaving only 8% not working due to another reason.
In an interview with St. Louis Public Radio, Todd Richardson, the director of Missouri’s Medicaid program, said the state would look into using an online portal to streamline the process for enrollees.
“Our goal is to make sure that people who are eligible and entitled to be on the program have the easiest path to get access to those benefits, while at the same time ensuring that those who are not eligible for the program are not on the program,” he told the outlet.
“If they’re working and we can verify that they’re working through income data, then that’s a verification right there,” Richardson added. “Now, there are other exceptions to the work requirements that probably will require a participant to send some documentation or to involve a human. But I think there’s a lot of that income verification that can be done electronically.”
Reduction of federal support for the program and the ways that states can fund Medicaid will leave Missouri lawmakers with a tricky budget situation in the years to come. Because the state’s expansion came through a voter-approved constitutional amendment, lawmakers won’t be able to easily undo the expansion, and the state is on the hook to pay for the full cost of the program.
States may turn to other programs to find ways to recoup the costs.
Missouri offers benefits through Medicaid beyond what is required by the federal government. Things like dental coverage, some mental health coverage, long-term care or Missouri’s recent expansion of Medicaid for postpartum women could be targets for cuts.
“I imagine they’re pretty nervous about this,” McBride said. “Frankly, those of us who just want the state to function are nervous for them because we want them to be able to do this. It’s really potentially catastrophic for the state.”
Otherwise, McBride said, programs like education, roads or prison funding would be likely places for the state to turn.
“The other options are to cut spending elsewhere,” McBride said. “They would cut Medicaid in places where they can cut Medicaid, and I’m pretty sure the state would have to cut from all of the above.”
How could work requirements look in rural Missouri?
New work requirements pose hurdles in rural parts of the state that urban areas may not face. Completing the necessary paperwork with unreliable internet or technology access could add another layer of difficulty.
Things like access to transportation, or a job with enough hours, could set Missourians back from obtaining coverage, said Caldwell-McMillan.
“It’s finding a job, and finding a job that is going to give you enough hours all of the time when they’re checking eligibility requirements,” Caldwell-McMillan said. “Retail workers, cashiers, cooks, those shifts can change. All of those folks are very much at risk — although they’re working — of not exactly meeting the hourly requirements and at risk of losing coverage.”
Navigators like Wehner will have to consider ways to help people report their work or caregiving when they may not have much access to technology.
“A lot of people I work with live out in rural areas. They may not even have a smartphone and definitely not internet access,” Wehner said. “So just to report things online is going to be really burdensome.”
Other trickle-down impacts could also hit rural Missouri the hardest. Rural hospitals, for example, rely heavily on Medicaid reimbursements to keep their doors open. Most recent data show 44% of rural hospitals have negative margins.
The budget package includes $50 billion for a rural hospital fund, which is equal to about one-third of the estimated loss of federal Medicaid funding in rural communities. The budget provides $10 million a year for five years for the fund, but health economists and Medicaid experts say the federal spending will be finished before many of the losses to Medicaid funding are fully realized.
Coupled with cuts to SNAP, the potential loss of a hospital in a rural area could be damaging to local economies, Caldwell-McMillan said.
“Many of those counties are the folks who are facing perhaps a closure of a clinic or the closure of the closest hospital because of cuts to Medicaid,” Caldwell-McMillan said. “So it really is a perfect storm of folks — working families — who need the support, and then two big sources of support are going to be taken away.”
“There’s going to be really tough choices and really tough consequences.”
