The process of formulating policy is subtly illuminating. A state starts rushing to comply with a federal mandate that is presented in terms of accountability and community involvement, even though its own data subtly indicates that the issue it is attempting to address might not be exactly what legislators had in mind. That’s about where Missouri is at the moment.
Medicaid enrollees nationwide, particularly those who obtained coverage through the expansion of the Affordable Care Act, will be required to record at least 80 hours per month of employment, education, volunteer work, or caregiving beginning in December. The One Big Beautiful Bill Act, a comprehensive piece of federal spending legislation that was passed last year, contains this clause. Promoting “agency” and “community engagement” among recipients is the declared objective. What happens to those who slip through the cracks of a new reporting system is the practical question.
This is why Missouri’s situation is so intriguing. Using data from the 2024 U.S. Census, researchers at the Washington University Center for Advancing Health Services, Policy and Economics Research discovered that roughly two-thirds of working-age Missourians on Medicaid—those between the ages of 19 and 64—are already employed. Thirty-eight percent are employed full-time. A further 29% are part-timers. The majority of people who are unemployed cite retirement, caregiving obligations, illness, or disability as their reasons. Merely 12% of those in that age group said they were unemployed for “other reasons.”
Thus, you have a policy based, at least in part, on an opinion of Medicaid recipients that doesn’t seem to be supported by the data.
One of the authors of the policy brief, Tim McBride, a professor of public health at Washington University, was quite straightforward about it. He calculated that about 40,000 Missourians who are neither employed nor covered by an exemption would eventually be subject to the new regulations. It will cost actual money to set up the reporting infrastructure, staff it, keep an eye on compliance, and maintain it for that segment of the population. To update the state’s software and get ready for the new requirements, Missouri legislators have already approved nearly $50 million in state and federal funding. “It seems like a lot of staffing and a lot of dollars to be spent on around 40,000 people,” McBride stated. Additionally, he said something worth considering: “I think it comes from a misperception of Medicaid recipients.”
Geographical factors make Missouri’s situation more complex than the national average. Approximately 30% of Medicaid beneficiaries in the state reside in rural areas, which is about twice the national average. The majority only have a high school degree or less. That combination is important. It probably makes it more difficult for these people to find employment with health benefits, and it might also indicate that there aren’t as many volunteer or community service opportunities nearby that would meet the 80-hour monthly requirement. McBride made this point very clearly: if there is a work requirement, there must be open positions or volunteer opportunities to meet it. That isn’t always the case in rural Missouri.
In order to minimize the need for direct communication with recipients, state officials have stated that they want to make compliance as easy as possible through online portals and income data already held by state agencies. Only six states nationwide have announced plans to use artificial intelligence to help manage the workload, including Missouri. Data matching, document processing, client interactions, and more automation could all be handled by the AI. Although the details are still unclear, it’s an ambitious vision.
Whether any of that will be sufficient to keep eligible individuals from losing coverage because they were unable to successfully navigate a new bureaucratic reporting process in time is still up for debate. That worry has been voiced by critics on numerous occasions, and it is not irrational. It is frequently the case that the difference between policy intent and policy outcome is precisely that large.
Federal guidelines are still pending, but Missouri is anticipated to reveal the specifics of its reporting program later this year. Approximately 1.26 million Medicaid recipients in the state are waiting until then; the majority of them are already employed, making contributions, and fulfilling their obligations under the policy.
