Native Americans and Alaska Natives are exempt from the Medicaid work requirements that take effect in January in 43 states and the District of Columbia. Native Hawaiians are not, an omission documented this month in reporting by KFF Health News and Honolulu Civil Beat.
Hawaii's Medicaid administrator, Meredith Nichols, said the Centers for Medicare and Medicaid Services did not respond to the state's request to add an exemption for Native Hawaiians. She attributed the outcome to the population's lack of recognition as a tribal nation, saying that when the state has asked similar questions in the past, "it all comes down to federal recognition."
Hawaii has about 390,000 Medicaid enrollees, 15% of whom identify as Native Hawaiian, according to Nichols. The reach extends well beyond the islands. Of the nearly 700,000 Native Hawaiians in the United States, about 47% live in Hawaii, with the largest mainland populations in California, Washington, Nevada, Texas and Oregon.
The Recognition Rule Behind the Gap
Several federal laws describe Native Hawaiians as an Indigenous group, but they are not among the 575 tribes recognized by the federal government. Recognition can come from Congress or through a Department of the Interior process, and Native Hawaiians themselves remain divided on whether to seek it, with some concerned it would foreclose claims to Hawaiian independence.
Medicaid statute reflects that gap. The federal government fully reimburses Indian Health Service and tribal facilities for care provided to Native Americans and Alaska Natives. Native Hawaiian health systems receive the same reimbursement rate as any other provider in Hawaii. The one exception was temporary: the 2021 American Rescue Plan Act fully reimbursed Native Hawaiian health centers for Medicaid services for two years.
Hawaii health administrators met with federal officials in June, and some pushed unsuccessfully for an exemption, which would require congressional approval. A CMS spokesperson confirmed the agency met with 16 Hawaii health centers about the Medicaid changes but did not answer other questions.
Rep. Jill Tokuda of Hawaii linked the exclusion to a broader pattern, saying of recent federal actions and lawsuits, "This is a targeted, coordinated attack to undercut the Indigenous status of Native Hawaiians." That characterization is her assessment, not a documented federal finding.
Who Is Exempt and Who Has to Document Hours
The requirement applies to most adults in the Medicaid expansion group, who must work, attend school or a training program, or volunteer at least 80 hours a month unless an exemption applies and is documented. KFF's tracker of state work requirement rules lists which states are covered.
Exempt categories include Native Americans and Alaska Natives, along with several groups defined by pregnancy, caregiving, student status, or medical frailty. Homelessness is not on the federal list, a gap MedicalDaily has previously reported on.
Exemptions are not automatic. People who qualify generally still have to document that they do, which is why advocates describe the largest risk to coverage as paperwork rather than employment.
The practical obstacles in Hawaii are specific. Leinaala Kanana of Waianae Coast Comprehensive Health Center said many of its patients are geographically isolated with few local jobs, limited transportation and scarce affordable childcare. The center estimated about 2,800 of its patients could be affected, half of them Native Hawaiian. CEO Rich Bettini put the gap plainly, noting that the annual cost of living for a family of four on Oahu exceeds $100,000 while the average income of the center's patients is under $30,000 a year. "That is an enormous gap," he said.
Enrollment Systems Are Already Backed Up Elsewhere
The administrative strain is not hypothetical, and it is not confined to Hawaii. In Texas, the Medicaid application backlog grew from about 1,600 in January to more than 210,000 in August, and the share of applications processed within the federal 45-day standard fell from above 90% to 62% by late August, according to state data in reporting by KERA on the Texas application backlog.
Diana Forester of Texans Care for Children told KERA that the median processing time has climbed from about 50 days to roughly 70. For families, she said, that means weeks of not knowing whether a child has coverage or whether prenatal care can begin. The Texas Tribune's account of processing delays reports that new federal requirements are landing on an eligibility system already under strain.
Anyone enrolled in Medicaid in an affected state can take three concrete steps now. Confirm that the state Medicaid office has a current mailing address and phone number, since notices drive the entire process. Determine whether an exemption applies and what documentation the state accepts. Keep copies of pay stubs, school enrollment, volunteer records or clinical letters in one place.
Community health centers and Medicaid navigators can help with applications at no charge. People who receive a termination notice should ask about appeal rights immediately, since deadlines are short and coverage can sometimes continue during an appeal if it is filed in time.
There is also a health consequence specific to Hawaii worth naming. Medicaid there covers transportation when patients travel between islands for care, and a round trip between Kauai and Oahu can cost hundreds of dollars. Losing coverage removes both the appointment and the means of reaching it, which is a different problem from a missed copay.
What remains unresolved is whether Congress adds a Native Hawaiian exemption, how many enrollees nationally will lose coverage for administrative reasons rather than eligibility ones, and how states with existing backlogs will absorb the additional verification work.
Key Questions Answered
When do the work requirements start? In January, in the 43 states and the District of Columbia covered by the rule.
Who has to comply? Most adults in the Medicaid expansion group, who must document at least 80 hours a month of work, school, training, or volunteering.
Who is exempt? Native Americans and Alaska Natives, along with groups defined by pregnancy, caregiving for young children, medical frailty, and full-time student status.
Why are Native Hawaiians not exempt? Hawaii officials say it comes down to federal recognition. Native Hawaiians are not among the 575 federally recognized tribes, and the Medicaid statute does not separately name them.
What is the biggest risk to coverage? Losing it over paperwork. People who are working or exempt can still be dropped if they miss a notice or cannot produce documentation.
Does this affect people outside Hawaii? Yes. About 53% of Native Hawaiians live on the mainland, with the largest populations in California, Washington, Nevada, Texas, and Oregon.
What should enrollees do now? Update the mailing address on file, confirm exemption status, gather documentation, and contact a community health center or navigator for free help.
