New data contradict a common misperception that many working-age Medicaid recipients are able-bodied but not working, according to a policy brief from researchers at Washington University in St. Louis.
The analysis finds that about two-thirds of Missouri Medicaid recipients ages 19 to 64 already are employed, a rate similar to national levels. Many of those who are not working report circumstances such as illness, caregiving or retirement that may qualify them for exemptions under new federal work reporting requirements.
The findings come as states begin implementing new work reporting requirements under a 2025 federal law often referred to as the "One Big Beautiful Bill Act." The law directs states to require many Medicaid recipients, primarily adults ages 19 to 64, to regularly document they are working or participating in approved activities, such as job training, education or community service, to maintain coverage.
In addition, Missouri legislators are considering a bill that would codify the federal requirements - and in some cases even stricter rules - in the state Constitution if approved by voters.
Researchers say the central risk may not be whether people qualify for Medicaid but whether they can repeatedly prove it through the reporting system. Under the new requirements, recipients must verify work or qualifying activities by submitting documentation such as pay stubs or enrollment records through a state portal, by mail or in person. For many, that process may determine whether they stay insured.
Barriers can include limited internet access, difficulty navigating online systems, transportation challenges and competing demands such as caregiving or unstable work schedules.
"This is a big issue that we are very worried about," said policy brief co-author Timothy D. McBride, the Bernard Becker Professor in the School of Public Health and co-director of the Center for Advancing Health Services, Policy & Economics Research. "For the last several years, we have documented the challenges recipients face in trying to comply with procedures with the state Medicaid agency. Many recipients have already been shown to lose coverage for these reasons, and our recent analysis suggests that over 90% of those who lost coverage lost it due to procedural reasons, not because they are ineligible."
The brief, co-authored by statistical data analyst Sarah A. Eisenstein, is based on 2024 U.S. Census data.
Most already meet requirements
Among working-age Medicaid recipients in Missouri:
- 67% are employed, including 38.6% full time and 28.6% part time
- About 14% are not working due to disability or illness
- About 4% are caregiving for a child under age 6
- About 4% are in school or retired
- About 11.5% report no identified reason for not working
Though broadly similar to national estimates, Missouri shows a higher share reporting disability or illness - 14% vs. 10% nationally - which may reflect greater health challenges in the state.
More than 1.3 million Missourians are enrolled in Medicaid, including children, seniors and people with disabilities. Among adults subject to work requirements, about 40,000 are not working and may not qualify for an exemption, representing a relatively small share of Medicaid recipients. "The findings raise questions about what is achieved by work reporting requirements, given the cost of implementing them," McBride said.
McBride also pointed out potential challenges tied to work reporting requirements. When patients lose Medicaid coverage, unpaid medical bills don't disappear, he said. Hospitals absorb the costs, governments step in with taxpayer funding and the rest is shifted through higher prices and insurance premiums. Preventive care covered by Medicaid is often far less expensive than treating conditions later, after they have worsened into more serious medical crises.
Characteristics of Missouri Medicaid recipients
The data also underscore the economic and geographic realities shaping Medicaid coverage in Missouri. Nearly 30% of Medicaid recipients in Missouri live in rural areas - about double the national rate - where jobs are less likely to offer health insurance. As a result, many rely on Medicaid for full benefits at little or no cost.
Most adults qualify for Medicaid with incomes around $20,000 a year for an individual or about $34,000 for a family of three, with eligibility also shaped by factors such as household size, disability, pregnancy and caregiving status. The Missouri Medicaid population reflects those constraints: more than half of Medicaid recipients have a high school education or less, limiting access to higher-paying jobs with benefits, and 40.7% fall below the poverty line versus 34.1% nationally. About 68.7% of Missouri recipients are white, versus 47.5% nationally, mostly reflecting the differences in the makeup of the population here.
The analysis also suggests that some people who appear not to be working may actually be providing unpaid care for family members, a role that is not fully captured in the data. If those individuals qualify for exemptions, even fewer people may fall outside the rules than the numbers suggest.
A shifting Medicaid population
Missouri's Medicaid population has shifted considerably in recent years, shaped by growth during the COVID-19 public health emergency, expansion approved by voters in 2020, and the unwinding of pandemic-era coverage protections after May 2023.
Using 2024 data from the U.S. Census Bureau's American Community Survey and other sources, the brief provides a snapshot of a population that is largely working or facing structural barriers to employment - raising new questions about how work reporting requirements will function in practice. The Missouri Foundation for Health supported the research.
