Rural Communities at Greater Risk of Harmful Impacts from New Medicaid Work Reporting Requirements 

In 2025, Congress passed H.R. 1, legislation¹ which requires work reporting requirements as a condition of Medicaid eligibility in the 41 states, including Washington, D.C., that have expanded coverage to most low-income adults under the Affordable Care Act.² (These mandated reporting requirements also apply in at least two non-expansion states, Wisconsin and Georgia, that cover an “expansion-like” population through a Section 1115 waiver.)³ In all these states the new work reporting requirement rules apply to adults ages 19-64 with incomes at or below 138 percent federal poverty level ($22,025/yr in 2026) and of this group of adults, the new rules will not apply to the overwhelming majority of parents and caretaker relatives living with a child. However, a small subset of parents and caretaker relatives with Medicaid expansion coverage may have to meet the new work
reporting requirement rules if their household income is below $580 per month.⁴ The new law mandates that all states require those not meeting an exemption report at least 80 hours of work or alternative “community engagement” activities per month when they apply for Medicaid and at renewal, which will now occur every six months, or lose their Medicaid coverage.

This issue brief explores how work reporting requirements will affect people living in rural areas and their communities. Non-elderly adults in rural areas are covered by Medicaid at higher rates than those living in urban areas. Rural counties are more likely to have higher unemployment rates making finding and keeping jobs more difficult.⁵ And there are reasons to be concerned that statutory exemptions will be harder to access for those living in rural areas. Many characteristics of rural areas, from poorer health status to lack of broadband access to limited economic development, will affect how people can qualify for and keep their Medicaid coverage under new work reporting requirements.

Section I: Medicaid Coverage and Indicators of Health in Rural Areas.

Medicaid benefits rural areas by keeping people healthy and allowing them to work and contribute to the community. Medicaid also protects rural residents from high medical debt or even bankruptcy. Medicaid also benefits rural areas by helping rural health clinics and rural hospitals deliver health care while getting reimbursed for the services they provide.⁶

Medicaid for women of childbearing age is important for the health of mothers and children. And Medicaid is even more important for women in rural areas and small towns than in urban settings. Nationally, 23.3% of women of childbearing age in rural areas are covered by Medicaid as compared to 20.5% of women in metro areas. Even more significant, the 10 states where the share of women of childbearing age in rural areas covered by Medicaid is the highest are all states that have expanded Medicaid. Work reporting requirements will thus disproportionately affect this group of rural women as well.⁷

People living in rural areas experience somewhat higher rates of disability compared to people living in urban areas. One study reported that people in rural areas were 9% more likely to report having any disability as compared to people in urban areas of similar age, sex, race, and income levels.⁸

Other studies have shown a smaller difference using different methods.  The US Census Bureau’s most recent analysis estimates that people in rural areas are slightly more likely (14.7% in rural areas v. 12.6% in urban areas) to report a disability.⁹ However, since the Bureau’s overall estimate is that 42.5 million Americans have a disability, even small differences between urban and rural areas translate into hundreds of thousands of people with disabling conditions.¹⁰

In addition to higher rates of disability, overall health measures are often significantly different between rural and urban areas. There are multiple drivers of this disparity. First, people who live in rural areas and small towns are more like to lack access to health care services, are more likely to be uninsured, and in general have less access to overall public health services. Second, rural areas experience higher overall poverty rates and lower incomes. Finally, there are lower rates of adoption of positive health behaviors in rural areas as compared to more metropolitan areas.¹⁷ For example, inequitable opportunities for physical activity in rural communities can be driven by the availability of fewer sidewalks and parks as compared to urban communities. This lack of infrastructure has a direct impact on the ability to be active and get exercise.¹⁸ These drivers of health disparities have a cumulative effect. There is an approximately two-to-three-year gap in older Americans’ life expectancy in rural areas as compared to urban areas.¹⁹

Finally, Americans in rural areas often experience significantly higher rates of chronic conditions like arthritis, diabetes and coronary artery disease.²⁰ Diabetes, a leading cause of death, is a particular problem in rural America. The prevalence of diabetes in some rural areas is 17% higher than in urban areas.²¹

Section II: Multiple barriers face people in rural areas in meeting Medicaid work reporting requirements.

According to the U.S. Department of Agriculture, rural areas overall have higher job loss and slower employment growth than urban areas. Labor force participation rates decreased much more in rural areas after the 2007-09 Great Recession as compared to urban areas and recovered much more slowly over the following decade. And even prime-working-age unemployment rates, which control for the exodus of younger people from rural areas, declined significantly less in rural areas compared to urban areas in the decade after the Great Recession.²² And residents in rural areas are 10.4% less likely to be offered health insurance through their jobs than urban workers are.²³Jobs available to residents of rural areas are more likely to be with smaller employers and in industries like agriculture and retail, where job-based health insurance coverage is less common.²⁴

Since there are often fewer job opportunities in rural areas and small towns as compared to urban areas, people in rural areas will simply have a harder time meeting the new Medicaid work reporting requirements than people who live in more urban settings.

Federal law does provide an alternative to meeting work reporting requirements for affected Medicaid enrollees: the equivalent time spent in “community engagement” or volunteer activities and/or education.

Rural communities have higher rates of volunteering than urban communities, reflecting personal connections to volunteer organizations and a tradition of working to build or create what is needed without outside support.²⁵ This could be a promising path for residents of rural communities to meet reporting requirements although subject to the reporting barriers discussed below. However, researchers have found that volunteer work and opportunities in both rural and urban communities are not “one-size-fits-all.” Opportunities are very dependent on the number and activities of nonprofit volunteer organizations and community-involved small businesses in the area. As a recent study found:

Nonprofit density amplifies volunteering in both rural and urban communities. Across the country, one pattern is remarkably consistent: more nonprofits mean more opportunities and more volunteer engagement.²⁶

And other researchers found:

Inconsistent infrastructure across rural communities and local capacity are critical areas for consideration when seeking to foster volunteering in rural under-resourced areas. Lack of resources, collaboration, professionalism, and investment of rural volunteer organizations limit growth and effective volunteer solutions.²⁷

So, while some rural communities may have more volunteer opportunities and participation than urban communities, this is not a given and heavily dependent on the organizations and makeup of the community itself.

And there is a further complication for rural communities.  The federal Centers for Medicare and Medicaid Services (CMS) interim final rule (IFR)²⁸ on work reporting requirements adds an additional requirement not appearing in the federal statute passed by Congress that implemented Medicaid work reporting requirements.²⁹  The IFR defines “community service” to meet the WRR as “unpaid work, completed voluntarily or because of a mandate by court order, with a structured program that is completed for the direct benefit of the community under the auspices of public or nonprofit organizations.” The organization providing the “structured program” does not necessarily have to be a formal 501c3 nonprofit but must be overseeing an organized volunteer program to benefit the community and can track participants’ hours of community service.³⁰ The IFR also specifically says that informal volunteer work – like helping a neighbor complete yard work on a regular basis – that is outside of the organizational structure does not count towards the WRR “community service requirement.³¹

This last interpretation of what counts as “community service” really strikes at the heart of what volunteerism means in some rural communities.  If the community is without formal organizations – either nonprofit or otherwise – that engage in “community wide” efforts, there will simply be fewer opportunities to meet the “community service” requirement of the WRR. This limitation may also apply to organizations that don’t have the administrative capacity to formally track a volunteer’s hours and services provided.  In addition, this definition ignores surveys that show almost twice as many Americans informally volunteer in their communities than formally volunteer with an organization – and often the most rural states are the states that have the highest percentage of residents engaging in informal “neighbor helping neighbor” volunteer activities.³²

H.R. 1 requires that people in the Medicaid expansion category applying for Medicaid or renewing their coverage meet the new work reporting requirements if they are not deemed exempt.³³ States must use available information they can already access to try and determine if a person applying for or renewing Medicaid meets the requirements. If that process is not successful, then states must notify the applicant and give them 30 days to show they meet the work reporting requirements. This will mean significant numbers of people must prove compliance during the application or renewal process.³⁴

So far, the guidance from the federal government based on H.R. 1 is that this notice must be sent by mail (or email but only if elected by the individual) and through one other method such as telephone, email, a text message, or other “commonly available electronic means.”³⁵  The individual must then report compliance through one of these methods – either online, in-person, mail or telephone.³⁶

An already complicated process, this notification and reporting requirement will face more barriers in rural communities.

First, online notification and website-based reporting face rural barriers. In rural communities, the cost of bringing broadband infrastructure is higher than in urban areas, leading to less access.  In addition, there is the additional cost of getting community members themselves connected and online with affordable service. Rural communities may have broadband access but not all customers in rural communities will be able to purchase such access or have the devices and ability to use the technology.³⁷

With states likely to require regular reporting of work requirement or community engagement documentation through internet services, this is another significant barrier to rural community members using Medicaid. Rural residents who are meeting the new work reporting requirements may well lack the digital infrastructure necessary to fill out the required paperwork.

Second, in-person reporting faces barriers in rural communities, as well. Recent research has shown that counties with high rural populations are 18.7% less likely to have a state office where residents can apply and renew Medicaid in-person. Because of the complexity of the requirements, face-to-face interactions may be of significant help during the application and renewal process. Rural residents have less access to in-person help.³⁸

Third, using the United States Postal Service poses more challenges in rural communities. In its proposed rule implementing multiple new paperwork reporting and notice requirements, the federal government acknowledges several times that the vast majority (75%) of people getting health coverage through Medicaid rely on the U.S. Postal Service to receive critical notices about their Medicaid coverage rather than electronically.³⁹ However, recent postal service changes aimed at cost savings, mean First Class mail and other mail takes longer to be collected and delivered to rural communities than in urban areas. These changes are projected to continue.⁴⁰

Work reporting notification and reporting via the U.S. Mail will take longer in rural areas, disadvantaging rural residents by making timelines for notification, reporting and compliance using this method significantly shorter than in urban areas.⁴¹

Under H.R. 1, people on Medicaid are exempt from work reporting requirements if they are “medically frail” or as defined under the statute as meeting any one of five criteria: having a disability, substance use disorder, disabling mental health condition, functional impairment impacting activities of daily living, or a serious or complex condition. But the interim final rule⁴² on work reporting requirements adds an additional requirement not appearing in the statute. The IFR now defines “medically frail” not only as having a specified medical condition but now adds a new requirement that states must determine if the person with the medical condition also is incapable of performing 80 hours a month of work or volunteer activities.⁴³ This means states must develop systems that not only identify people who have a medical diagnosis that puts them in the “medically frail” category, but also have other health professionals – presumably doctors – make determinations about the ability of their patients to work at specific jobs, a task that seems far removed from the provision of medical care.

This requirement will exacerbate the problem of too few medical professionals often available in rural communities⁴⁴ as this will likely create a new duty for doctors – assessing the ability to work of people with medical conditions that would typically keep them from working full time.  If people with conditions that make them medically frail are required as part of the assessment process to travel to a Medicaid office, the fact that few Medicaid offices are in rural areas will also adversely impact the ability of people in rural communities to obtain a WRR exemption because of medical fragility.  Finally, the type of work available in rural communities may be different than in more urban areas. It is not clear from the IFR how (or even if) the type of work available in a community will affect the ability of a patient to get an exemption based on medical frailty. For example, a patient with cancer may be judged able to perform an office job on a computer but not able to work construction or in the service industry. 

A final additional barrier facing people in Medicaid with a condition that makes them medically frail involves the issue of “self-attestation” or the idea that states can get people on Medicaid to provide their own assessment of the severity of their health condition and ability to meet work or volunteer requirements for 80 hours a month with that condition. The IFR says that while states may optionally decide to allow such “self-attestation” until 2028, all states after that date will be required to provide documentation for each determination of medical frailty beyond one initial self-attestation from the Medicaid recipient, another requirement that did not appear in the statute passed by Congress.⁴⁵ 

The restriction on the use of self-attestation will exacerbate the administrative burden for individuals, Medicaid agencies, and health care providers. Given the more limited access for doctors and health professionals in rural areas, the restriction on self-attestation will be more impactful on rural residents.

Federal law does allow states to request a hardship exemption from work reporting requirements for people on Medicaid who live in counties with high unemployment rates – 1.5 times or more of the average national unemployment rate or at or above 8% unemployment.  This exemption could address the issue of higher unemployment rates and more job loss in rural communities for people on Medicaid trying to meet the new work requirement standards. Under the proposed IFR by CMS implementing H.R. 1, states are given latitude as to what unemployment data to use if they do wish to request a hardship exemption based on the unemployment rates in a particular area.  States may use the U.S. Bureau of Labor Statistics as the standard for determining unemployment rates and may adjust those statistics with another reliable source or use another source entirely as long as it is deemed reliable.  So, a state would be allowed to incorporate the effects of an event like a factory closure in a particular county.⁴⁶

Looking at the enormous variation in unemployment rates between counties nationwide for example shows how these disparities could play out for rural areas.⁴⁷ Under one possible definition of how to measure county unemployment rates, the two states implementing work reporting requirements early, Nebraska and Montana, would have significantly different outcomes. Nebraska would have no counties exempt from work reporting requirements while Montana would have six counties exempt.⁴⁸ Further complicating the picture in Nebraska, the state recently received an exemption for the work reporting requirement for one county, Dawson, experiencing high unemployment after the closure of a major meatpacking plant closure.⁴⁹

And not only is there the potential for extreme variation in how this exemption is applied, but residents in urban areas may benefit the most from exemptions. A recent attempt at estimating the number of counties that could potentially be exempt found that only about 7% of counties and enrollees in Medicaid expansion states would meet exemption criteria. About 80% of these counties are in rural areas – however since the total population is so much higher in urban counties, 80% of people covered by Medicaid who could be exempted from work reporting requirements under this exemption live in urban counties.⁵⁰

Overall, there are multiple states with no qualifying counties and many states with five or fewer qualifying counties. This makes the exemption extremely limited. In addition, a recent survey found that while most states plan to use the unemployment exception, four states – Indiana, Iowa, Missouri, and Oklahoma – do not plan to adopt it.⁵¹

Finally, there is one further complication with states applying the unemployment hardship exemption under CMS’s proposed rule.  The proposed IFR is written to require that states implement not only the unemployment exemption but all four of the short-term hardship exemptions as defined in the statute.⁵² The other exemptions include people receiving certain medical services in a hospital or nursing facility, residing in a county with a federal-declared emergency or disaster, or traveling outside their community for an extended period to receive medical services for a complex medical condition for themselves or a dependent.  It remains to be seen whether requiring all four of these exemptions to be adopted means that states are more or less likely to adopt them all as a group.    

Conclusion

A strong work ethic is a significant part of rural identity. Most adults covered by Medicaid – whether in rural or urban areas – are working. If they are not working in a regular full-time job, they are a family caregiver, attending school, working part-time or seasonal jobs, self-employed, or are otherwise engaged in the community.⁵³ And recent research has shown that of the minority of people 18-64 covered by Medicaid who are not working, many are lower-income older women who have left the workforce to care for family members.⁵⁴ 

Since most people subject to the new work reporting requirements are already working, the additional problems in meeting these new standards in rural areas as opposed to urban areas are as much a systemic issue of lack of infrastructure and investment rather than an individual’s desire to work and meet the new mandates. If there is less investment by states and the federal government in economic development, mail services, and closing the digital divide in rural areas, this will make it harder for people to meet the new requirements. If there is less state and federal support for rural health clinics and hospitals in rural areas and if there are fewer nonprofits and formal, official “volunteer opportunities” in rural areas, people covered by Medicaid in rural areas will also face more barriers to meeting these new requirements.

Endnotes

1. Park, E., & Corlette, S. (2025, July 22). Medicaid, CHIP, and Affordable Care Act Marketplace cuts and other health provisions in the budget reconciliation law, explained. Georgetown University McCourt School of Public Policy, Center for Children and Families. Available Here. ↩︎
2. Mathers, J., Tolbert, J., Chidambaram, P., & Cervantes, S. (2025, April 25). 5 key facts about Medicaid expansion. KFF. Available Here. ↩︎
3. Brooks, T., Kohler, A., Cuello, L., Whitener, K., & Jade Little, J. (2026, July 16). New Federal Medicaid Work Reporting Requirements Rule Threatens Coverage for Vulnerable Americans: An Explainer of the Interim Final Rule. Georgetown University McCourt School of Public Policy, Center for Children and Families. Available Here. ↩︎
4. Kohler, A., & Alker, J. (2026, August 26). How Are Parents Impacted By Medicaid Work Reporting Requirements? Georgetown University McCourt School of Public Policy, Center for Children and Families. Available Here. ↩︎
5. Bell, C., Tolbert, J., & Cervantes, S. (2025, September 29). A look at the potential impact of the high unemployment hardship exception to Medicaid work requirements. KFF. Available Here. ↩︎
6. Alker, J., Osorio, A., & Park, E. (2025, January). Medicaid’s role in small towns and rural areas. Georgetown University McCourt School of Public Policy, Center for Children and Families. Available Here. ↩︎
7. Alker, J., & Osorio, A. (2025, May). Medicaid plays a key role for maternal and infant health in rural communities. Georgetown University McCourt School of Public Policy, Center for Children and Families. Available Here. ↩︎
8. Zhao, G., Okoro, C. A., Hsia, J., Garvin, W. S., & Town, M. (2019). Prevalence of disability and disability types by urban–rural county classification—U.S., 2016. American Journal of Preventive Medicine, 57(6), 749–756. Available Here. ↩︎
9. U.S. Census Bureau. (2023, June). Disability rates higher in rural areas than urban areas. Available Here. ↩︎
10. Ibid. ↩︎
11. Burns, A., & Cervantes, S. (2025, February). 5 key facts about Medicaid coverage for people with disabilities. KFF. Available Here. ↩︎
12. Ibid. ↩︎
13. Ibid. ↩︎
14. Social Security Administration. (2024, March). FAQ, topic KA-01801: How long does it take to get a decision after I apply for disability benefits? Available Here. ↩︎
15. National Organization of Social Security Claimants’ Representatives. (2024, February). 2023 waterfall charts. Available Here. ↩︎
16. Burns, A., & Cervantes, S. (2025, February). 5 key facts about Medicaid coverage for people with disabilities. KFF. Available Here. ↩︎
17. Rural Information Hub. (n.d.). Rural health disparities: Life expectancy. Retrieved from Available Here. ↩︎
18. Kegler, M. C., Gauthreaux, N., Hermstad, A., Arriola, K. J., Mickens, A., Ditzel, K., et al. (2022). Inequities in physical activity environments and leisure-time physical activity in rural communities. Preventing Chronic Disease, 19, 210417. Available Here. ↩︎
19. Chapel, J. M., Currid-Halkett, E., & Tysinger, B. (2025). The urban–rural gap in older Americans’ healthy life expectancy. The Journal of Rural Health, 41, e12875. Available Here. ↩︎
20. U.S. Department of Health and Human Services. (2021, November). Chartbook on rural healthcare, National Healthcare Quality and Disparities Report. Available Here. ↩︎
21. Coughlin, S. S., Clary, C., Johnson, J. A., Berman, A., Heboyan, V., Benevides, T., Moore, J., & George, V. (2019). Continuing challenges in rural health in the United States. Journal of Environmental Health Science, 5(2), 90–92. Available Here. ↩︎
22. United States Department of Agriculture. (2026, February). Employment & education – rural employment and unemployment. Available Here. ↩︎
23. Larson, S. L., & Hill, S. C. (2005). Rural-urban differences in employment-related health insurance. The Journal of Rural Health, 21(1), 21–30. Available Here. ↩︎
24. Eisenstein, S. A., & McBride, T. D. (2026, March). Health insurance coverage in rural and urban Missouri: Update. Washington University, Center for Advancing Health Services, Policy and Economics Research. Available Here. ↩︎
25. Nesbit, R., & Paarlberg, L. (2026, January 19). Volunteering in rural and urban communities isn’t one-size-fits-all. Open Access Government, 49, 302–303. Available Here. ↩︎
26. Ibid. ↩︎
27. Points of Light Foundation. (2004). Volunteering in under-resourced rural communities. Policy Archive. Available Here. ↩︎
28. Centers for Medicare & Medicaid Services. (2026, June). Medicaid program; community engagement requirement for certain individuals (Proposed interim final rule). Federal Register. Available Here. ↩︎
29. An act to provide for reconciliation pursuant to title II of H. Con. Res. 14, H.R. 1, 119th Cong. (2025). Available Here. ↩︎
30. Centers for Medicare & Medicaid Services. (2026, June). Medicaid program; community engagement requirement for certain individuals (Proposed interim final rule, Sec. 435.552(b)). Federal Register. Available Here. ↩︎
31. Centers for Medicare & Medicaid Services. (2026, June). Medicaid program; community engagement requirement for certain individuals (Proposed interim final rule, p. 146). Federal Register. Available Here. ↩︎
32. USAFacts. (2024, December). How many Americans volunteer? In 2023, over a quarter of Americans volunteered formally and over half volunteered informally. Available Here. ↩︎
33. Schneider, A. (2026, February 11). Implementing costly Medicaid work reporting requirements: Who will foot the bill? Georgetown University, Center for Children and Families. Available Here. ↩︎
34. Meuse, D. (2025, August). Medicaid work reporting requirements: Implementation basics and state decision points. State Health and Value Strategies, Princeton University. Available Here. ↩︎
35. Brooks, T., Kohler, A., Cuello, L., Whitener, K., & Little, J. (2026, July 16). New federal Medicaid work reporting requirements rule threatens coverage for vulnerable Americans: An explainer of the interim final rule. Georgetown University, Center for Children and Families. Available Here. ↩︎
36. Centers for Medicare & Medicaid Services. (2025, November). “Working Families Tax Cut” legislation, Public Law 119-21: Summary of Medicaid and Children’s Health Insurance Program (CHIP) related provisions. U.S. Department of Health and Human Services. Available Here. ↩︎
37. Junod, A. N., & Scally, C. P. (2025, February). Expanding digital opportunity in rural communities. Urban Institute. Available Here. ↩︎
38. Lim, K., Goutos, D., Aswani, M., Benitez, J., Thompson, K., & Shafer, P. R. (2025). Racial, ethnic, and rural disparities in access to Medicaid offices. Health Affairs Scholar, 3(5), qxaf072. Available Here. ↩︎
39. Centers for Medicare & Medicaid Services. (2026, June). Medicaid program; community engagement requirement for certain individuals (Proposed interim final rule, p. 795). Federal Register. Available Here. ↩︎
40. Postal Regulatory Commission. (2025, January). Postal Regulatory Commission issues advisory opinion on USPS Delivering for America. Available Here. ↩︎
41. Postal Regulatory Commission. (2025, April). Postal Service implements nationwide changes to mail service. Available Here. ↩︎
42. Centers for Medicare & Medicaid Services. (2026, June). Medicaid program; community engagement requirement for certain individuals (Proposed interim final rule). Federal Register. Available Here. ↩︎
43. Ibid. ↩︎
44. National Rural Health Association. (2025, June). Rural physician burnout and staffing shortage impact in 2025. Available Here. ↩︎
45. Centers for Medicare & Medicaid Services. (2026, June). Medicaid program; community engagement requirement for certain individuals (Proposed interim final rule, p. 549). Federal Register. Available Here. ↩︎
46. Ibid. ↩︎
47. U.S. Bureau of Labor Statistics. (2026, January). Local area unemployment statistics, county unemployment rate tables. Available Here. ↩︎
48. Alker, J. (2026, April 23). Congress wanted to protect people living in areas with high unemployment from losing health care due to work reporting requirements. Will it actually happen? Georgetown University Center for Children and Families. Available Here. ↩︎
49. Byars, M. (2026, July 17). Dawson County granted temporary exemption from Medicaid work requirements due to high unemployment following Tyson closure. Nebraska Public Media. Available Here. ↩︎
50. Bell, C., Tolbert, J., & Cervantes, S. (2025, September). A look at the potential impact of the high unemployment hardship exception to Medicaid work reporting requirements. KFF. Available Here. ↩︎
51. Ibid. ↩︎
52. Centers for Medicare & Medicaid Services. (2026, June). Medicaid program; community engagement requirement for certain individuals (Proposed interim final rule, p. 365). Federal Register. Available Here. ↩︎
53. Tolbert, J., Cervantes, S., Rudowitz, R., & Burns, A. (2025, May 30). Understanding the intersection of Medicaid and work: An update. KFF. Available Here. ↩︎
54. Rosenbaum, S., Cohen, M. A., Tavares, J. L., & Barkoff, A. (2025, April). Who’s affected by Medicaid work reporting requirements? It’s not who you think. Milbank Quarterly. Available Here. ↩︎