Thirty of the 44 states required to implement Medicaid work requirements next year are holding a gubernatorial election Nov. 3. Most winners will take office in January, just as the new rules take effect.
HR 1 requires states to begin applying an 80-hour monthly work, school or volunteer requirement to most adults in the Medicaid expansion population by Jan. 1. Governors cannot waive the requirement, but they do have control over how it’s carried out, including how states verify compliance, which conditions qualify someone as medically frail and whether to ask CMS for more time. Election winners will also oversee the first year of enforcement, including the first coverage losses and stricter documentation standards that begin in 2028.
Of the 30 states with races, 13 have Republican governors and 17 have Democratic governors, according to a KFF analysis. The analysis noted that leadership transitions, particularly those that flip party control, could complicate implementation as new administrations bring new priorities and agency staff. Candidates in most of the closely watched races have offered few specifics on how they would implement work rules, speaking instead about Medicaid funding cuts and preserving coverage more broadly.
On Oct. 1, the governors of California, Maine, New Mexico, Oregon and Virginia asked HHS to delay the Jan. 1 deadline, citing changes CMS made in its June interim final rule. Separately, 25 states and the District of Columbia sued CMS in June over how the rule narrows the medically frail exemption. A federal judge in Massachusetts declined in July to block that provision and has indicated he intends to rule on the merits by the new year.
In Georgia, which never expanded Medicaid, the next governor will inherit a work rules program in transition. Pathways to Coverage, which covers adults up to the poverty line who meet a work requirement, must switch to the federal rules in 2027, and its current federal waiver expires Dec. 31. Democratic candidate Keisha Lance Bottoms has called Pathways a “complete disaster” and wants full Medicaid expansion, and her campaign said she opposes the “unnecessary bureaucracy” of work requirements. Republican candidate Rick Jackson has proposed a state-designed waiver that keeps work requirements, Atlanta News First reported.
In Pennsylvania, Democratic Gov. Josh Shapiro joined the multistate lawsuit over how the work rules are being implemented, and the state’s recent budget funds nearly 400 county assistance office positions to handle the added workload, Spotlight PA reported. The outlet also reported that Republican Treasurer and candidate Stacy Garrity has said she would work with the Trump administration to implement HR 1’s anti-fraud provisions, strengthen provider screening and order independent audits of the state’s Medicaid programs.
In Oregon, Democratic Gov. Tina Kotek has twice asked HHS to delay the requirements, most recently leading the Oct. 1 letter, KOIN News reported. Republican state Sen. Christine Drazan has not detailed how she would handle the rollout.
In Wisconsin, which also never expanded Medicaid, the requirements will apply to about 200,000 childless adults, according to the state. Republican Rep. Tom Tiffany has publicly spoken about his support for work requirements, while the Democratic candidate, Milwaukee County Executive David Crowley, has criticized Mr. Tiffany’s vote for HR 1 but has not detailed how he would handle the implementation if elected.
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