WASHINGTON — State officials say they need more information from the Trump administration before they can fully implement new requirements for Medicaid, according to a survey released Thursday by KFF and the Georgetown University Center for Children and Families.

Republicans’ “big, beautiful” law made several changes to the state-federal health program for lower income people and some people with disabilities, including that enrollees between the ages of 19 and 65 work, participate in community service, or attend an education program for at least 80 hours a month.

The survey of Medicaid program officials from 43 states showed the people tasked with implementing the law have questions about how exactly they should determine if someone meets the new requirements or is exempt. 

“In addition to how to define medical frailty, states wanted additional direction in many areas including what qualifies as community service, how to calculate half-time school attendance, and what is considered a ‘significant relationship’ to qualify for the caregiver exemption,” the report states. “They also indicated they need guidance about what sources can be used for verification, whether self-attestation will be allowed if other sources are not available, and how long verification of exemptions remain valid.”

The law includes several additional carve-outs, including for Medicaid enrollees who are pregnant, have dependent children, are tribal community members or are in the foster care system, and for individuals released from incarceration in the last 90 days, among others.

The vast majority of state officials surveyed said they would implement the new requirement for work, education, or community service at the start of next year.

There are, however, a few states moving forward earlier. 

Nebraska plans to begin May 1, Montana on July 1 and Iowa officials said they will begin this year, though they haven’t provided a date, KFF said. Arkansas has planned a “soft launch” for July but won’t actually remove anyone from Medicaid for not meeting the new requirements until next year, according to the report.

Hardship exemptions

The KFF-Georgetown survey says that nearly all states will allow hardship exemptions for people in counties with higher unemployment; those who recently experienced a natural disaster; those who have been admitted to a hospital or nursing facility; or those who need to travel outside their community for medical care.

Indiana and Iowa are the only two states so far that don’t intend to allow any hardship exceptions from the requirement that Medicaid enrollees work, attend community service, or enroll in an education program, the report said. 

“Oklahoma is not adopting the exceptions for residents of counties with high unemployment or with a declared natural disaster while Missouri is not adopting the exception for residents of counties with high unemployment,” the report says. “New York is not planning to adopt the exception for individuals traveling outside their community for medical care. Twelve states had not made a decision.”

Look-back periods vary

Thirty-six states will look back one month when someone applies for Medicaid to determine whether they’re working, participating in community service, or enrolled in an education program. Indiana and Idaho will look back at the last three months before the person applied to determine whether they meet the new requirement. 

Thirty-four states will look back one month during the renewal process, which must happen at least every six months under the law. 

“Indiana and New Hampshire will check quarterly and at renewal to verify that enrollees meet the requirements every month between renewals,” according to the report. “Arkansas will also look back three months at renewal but is not planning quarterly checks. States that had not made a decision at the time of the survey included five states for application, six states for renewal, and seven states for more frequent checks.”

CINCINNATI — For four years, Kimberly Dudley has worked on the front line of the Affordable Care Act as a navigator, helping Ohioans solve the puzzle of buying private insurance on the federal HealthCare.gov marketplace.

But the job is harder now, the answers scarcer. In one of its first acts, the second Trump administration cut annual funding for navigators by 90%, from $100 million to $10 million, arguing the program was wasteful. Under the ACA, better known as Obamacare, navigators help educate and enroll people — especially those living in hard-to-reach communities. They were paid through a user fee on monthly premiums.

In January 2025, 50 navigators served Ohio’s 88 counties, toting their laptops to meet Ohioans at rural libraries and suburban food courts to help them search for a health care plan on the marketplace. But by the Nov. 1 start of open enrollment, the busiest time of year, only five navigators remained. Dudley, of Cincinnati, is one of them.

Married with a child, she was hired in 2022 at Cincinnati’s Freestore Foodbank and found “such a joy from helping people, although it’s been hard this year.” The hotline, for example, is in Dudley’s hands now. The other navigators who worked calls were laid off.

The administration did not respond to requests last week to discuss the navigator program cut. But in announcing the cuts last year, an administration statement said: “Navigators are not enrolling nearly enough people to justify the substantial amount of federal dollars previously spent on the program. This reduction will ensure funding is focused on meeting the statutory goals of the program more efficiently and effectively.”

Dudley’s task got even tougher at the end of last year, when the Trump administration and Congress allowed certain pandemic-era subsidies to expire, and policy premiums rose sharply, often to more than many Ohioans can pay.

She hears the stories every day on her own phone, which doubles as Ohio’s ACA hotline. People call when they are ruled ineligible for Medicaid, usually because their incomes are too high. In early March, Dudley heard from Tonya Horn, 59, of Cleveland Heights, who needed help.

All her working life, said Horn, she felt lucky to have employer-paid health benefits up to her most recent job, working remotely for Empower, a Colorado financial services company, as a talent acquisition diversity program manager. But last year, her job at Empower felt less secure. Her pink slip came in January.

Helping Horn, Dudley spotted a plan on HealthCare.gov that with an income-based subsidy would cost $450 a month with no deductible. But then Dudley discovered that Horn’s doctor does not accept that insurance plan.

“I don’t know if this works for you,” Dudley said, “but getting insurance could involve switching doctors.”

Horn sighed. “Can we keep looking?”

Drop in enrollment

This year, Ohio’s enrollment in the HealthCare.gov marketplace fell by 20%, the second-largest decline among the 50 states. The overall national enrollment slid 5%.

Experts in Ohio said a few factors depressed enrollment. Some people aged into Medicare. Others found jobs with health benefits. But one certain force was the Dec. 31 expiration of the pandemic-era subsidies on most marketplace plans.

The ACA does provide premium subsidies based on income, but the federal government began offering additional help in 2021 as temporary pandemic relief. The “enhanced” subsidies cut many people’s monthly premiums by hundreds of dollars.

They also helped boost the number of people buying health coverage from the insurance marketplaces, from 11.4 million people in 2020 to 24.3 million last year.

Americans who had the enhanced subsidies got warnings from their insurers about the Dec. 31 expiration. As of March 26, the number of Americans with marketplace coverage dropped by about 1.2 million compared with 2025, according to the Centers for Medicare & Medicaid Services.

Last week, a spokesperson for U.S. Sen. Jon Husted, an Ohio Republican, said that Husted proposed to extend the subsidies two more years, with new restrictions to prevent fraud in marketplace plans. Democrats rejected the idea, said Joshua Eck, Husted’s deputy chief of staff. “But had they supported the bill, or been willing to discuss it, it’s likely this problem would have been solved in December.”

In Ohio, the Columbus nonprofit research group Health Policy Institute of Ohio found that of the more than 580,000 Ohioans with 2025 HealthCare.gov plans, nearly 90% used the temporary subsidies.

California and at least nine other states that run their own health insurance marketplaces have used state money to help residents absorb the expiration price shock, though only New Mexico is completely filling the gap. Ohio could not dip into its budget that way because it uses the federal marketplace.

In January, the Health Policy Institute of Ohio estimated that 2026 premiums for Ohio marketplace plans would surge by 114% on average. Said institute analyst Brian O’Rourke: “It’s reasonable to expect that (the enrollment drop is) because of the expiration of the subsidies.”

On the statewide ACA hotline call with Horn, Kimberly Dudley said her own mother got a notice from her insurance company that her $40-a-month premium would increase to $400. “I was able to help her figure out a plan, but her premium still went up some,” Dudley said. “We’re going to find a way forward for you.”

“I hope so,” Horn said.

Ohio expands the ACA

Ohio’s industrial base collapsed in the 1990s, and hundreds of thousands of workers lost employer-paid coverage. Young people left Ohio for work, and the insurance pool shrank as it rapidly aged. Numerous studies found Ohio’s health declining, in no small part because nearly 1.5 million Ohioans, more than 10% of the population, had zero health insurance.

The ACA also allowed states to expand Medicaid to adults with incomes up to 138% of the poverty level, although some Republican-led states have refused the expansion. In Ohio, GOP Gov. John Kasich pushed the Republican-led state legislature to approve the expansion in 2013; 40 states and the District of Columbia have expanded their programs. Ohio’s participation in the federal marketplace grew until 2025, when enrollment hit a record high.

The speed of the retreat in Ohio of the ACA brought swift consequences. The Columbus nonprofit group UHCAN Ohio “has been helping people since the law’s inception,” said Executive Director Charlotte Rudolph. Then last fall, “If we saw five people, maybe one enrolled. They’re making that tough decision to say, ‘I hope I don’t get sick.’”

“We are now going through our archives, asking ourselves, how did we help people back in the day when they didn’t have coverage?”

Further complicating Ohio’s health care horizon are Trump administration cuts to Medicaid. More than 3 million Ohioans use the health program for low-income residents. But under the broad tax and spending measure President Donald Trump signed last summer, as many as 1 in 10 of those Ohioans could be found ineligible through new work requirements and other hurdles.

Horn, on the hotline phone call, said her weekly $624 unemployment payments had put her over the Medicaid threshold. Dudley nodded as she tapped on her keyboard. “I hear that a lot,” she said.

What the future holds

While the immediate problems are stressing the system, experts say they are anxious for what is to come in Ohio’s health care.

Uninsured people often use emergency departments for primary care, straining hospitals still under pandemic duress and understaffed. Many Ohioans on Medicaid live in its rural spaces, where the safety net has long been fraying. The trade group the Ohio Hospital Association told the state legislature last year that more than 70% of the state’s rural hospitals have been running in the red for years.

“My fears,” said Grace Wagner of the Ohio Association of Foodbanks, “are that as these changes continue to come, decision-makers aren’t aware or prepared to respond.”

Dudley and Horn spent another 30 minutes on the ACA hotline, but none of the HealthCare.gov options clicked. Finally, Horn said she would call back.

“Sure, it’s a lot to think about,” Dudley said, and ended the call. Then she sat looking at her laptop screen full of HealthCare.gov. She doesn’t like to leave a puzzle unsolved for someone who came to her for help.

“I love what I do. Being able to do this work is fantastic, even in the midst of all this stuff happening,” she said. “But there are times when I feel a little overwhelmed.”