Series 14: State Implementation of Work Requirements
A 37-year-old woman in Barber County, rural southwestern Kansas, works at a local grain elevator earning approximately $14,000 annually. She has no employer-sponsored health insurance. She has asthma that worsens each harvest season from dust exposure, but she cannot afford an inhaler or preventive medications. She has no dependent children. She earns too much for Kansas Medicaid, which caps parent eligibility at approximately 38% of the federal poverty level. She earns too little for marketplace premium subsidies, which begin at 100% of poverty. The nearest hospital is 30 miles away. That hospital is projected to close within two years due to financial strain. She represents one of approximately 27,000 to 39,000 Kansans in the coverage gap: working poor in crumbling healthcare infrastructure, excluded from coverage because Kansas chose not to expand Medicaid.
H.R. 1, signed July 4, 2025, transformed Medicaid work requirements from a state-option policy experiment into a federal mandate affecting approximately 18.5 million expansion adults nationwide. The law requires 80 hours monthly of work, education, training, or qualifying community engagement activities, with semi-annual redetermination cycles for adults aged 19-64 who gained Medicaid eligibility under the ACA’s optional expansion. States that expanded Medicaid face a January 1, 2027 implementation deadline, though good-faith extensions are available through December 31, 2028 for states demonstrating genuine progress toward compliance infrastructure.
Kansas is not subject to these federal work requirements because Kansas never expanded Medicaid under the ACA. By declining expansion since 2014, the state ensured that no residents gained coverage through the expansion pathway that now carries work requirement conditions. The federal mandate applies exclusively to expansion adults, a population that does not exist in non-expansion states. This creates political irony: Governor Laura Kelly has proposed Medicaid expansion with work requirements every year since taking office in 2019, attempting to make expansion palatable to the Republican-controlled legislature through precisely the conditions that federal law now mandates. The legislature has blocked expansion repeatedly regardless.
Kansas has the highest percentage of rural hospitals at risk of closure of any state nationally. According to the Center for Healthcare Quality and Payment Reform, 67 of Kansas’s approximately 100 rural hospitals (67%) are at risk of closing, with 30-31 at immediate risk of closure within two to three years. Eight rural hospitals have closed since 2015. The February 2025 introduction of the Healthcare Access for Working Kansans (HAWK) Act marks Governor Kelly’s seventh attempt to expand Medicaid with work requirements. The Republican legislature has shown no willingness to advance the bill despite polling showing approximately 72% of Kansans support expansion.
Traditional Medicaid Eligibility and the Coverage Gap Structure#
Kansas Medicaid (KanCare) serves approximately 358,000 to 458,000 individuals, predominantly children, pregnant women, elderly, and disabled populations. The program’s eligibility structure for working-age adults creates a coverage gap that expansion would fill.
Parents with dependent children qualify only with household incomes up to approximately 38% FPL, or roughly $778 monthly for a family of three. This threshold is more restrictive than most expansion states but less extreme than Texas (14-17% FPL) or Alabama (18% FPL). A parent working full-time at minimum wage ($7.25 per hour) earns approximately $1,257 monthly before taxes, exceeding Kansas Medicaid eligibility. Most working parents are categorically excluded regardless of poverty level.
Children qualify with more generous thresholds: up to 166% FPL for infants under one, 149% FPL for children ages one through five, 138% FPL for children ages six through eighteen. The Children’s Health Insurance Program (CHIP) extends coverage to children with household incomes up to 242% FPL. Pregnant women qualify up to 154% FPL during pregnancy, with post-partum coverage ending at 60 days creating cliff effects for new mothers.
Adults without dependent children face complete categorical exclusion. A childless adult earning $0 per year cannot qualify for Kansas Medicaid. Disability (SSI eligibility) or age (65+) provides the only coverage pathway. This policy choice creates the fundamental coverage gap: approximately 27,000 to 39,000 adults earn below 100% FPL yet cannot access either Medicaid or marketplace subsidies.
The HAWK Act: Seventh Attempt, February 2025#
Governor Kelly announced the Healthcare Access for Working Kansans (HAWK) Act on February 6, 2025. The bill was introduced into both chambers: House Appropriations Committee by Representative Barbara Ballard, Senate Ways and Means Committee by Senator Pat Pettey. This marks Kelly’s seventh consecutive annual proposal for Medicaid expansion since taking office in 2019, continuing a pattern of gubernatorial support meeting legislative resistance that spans over a decade.
The HAWK Act would expand KanCare to adults earning up to 138% FPL, approximately 150,000 Kansans according to state estimates. The proposal includes work requirements from the outset as a compromise designed to attract Republican support: applicants must be employed, in school, engaged in volunteer work, or caring for a dependent child or incapacitated adult. The bill differs from work requirement proposals in other states by requiring proof of employment to enroll rather than specifying hours worked, though the legislative language references 80 hours monthly consistent with federal standards.
The HAWK Act includes a sunset provision: if the federal matching rate drops below 90%, the program phases out over 12 months. This provision addresses Republican fiscal concerns about long-term state obligations if federal funding structures change, effectively making expansion contingent on continued enhanced federal matching. The bill also establishes a 15-member Rural Health Advisory Committee appointed by the governor to address health issues and make recommendations.
The Republican legislature has not advanced the HAWK Act. Senate President Ty Masterson, a candidate for governor in 2026, has stated that he does not believe expansion is possible under the current legislature and has argued that expansion has not helped rural hospitals in other states. This stance persists despite the Kansas Hospital Association’s consistent support for expansion and state studies showing expansion would reduce hospital uncompensated care by at least 30%. The political calculus appears unchanged from previous years: conservative primary election dynamics create greater risk for Republican legislators who support expansion than general election consequences of blocking it.
H.R. 1 Changes to the Expansion Calculation#
The passage of H.R. 1 with mandatory work requirements occurred while Kansas continued operating outside the expansion framework. The law fundamentally changed what expansion would mean if Kansas ever pursues it.
The elimination of the American Rescue Plan Act’s temporary incentive for newly expanding states affects Kansas’s fiscal calculation. That provision would have increased the federal matching rate for Kansas’s existing Medicaid population by five percentage points for two years if the state expanded. For Kansas, with a projected FMAP around 58%, this would have meant hundreds of millions in additional federal funding during the two-year period. The Kansas Health Institute estimated Kansas would receive approximately $542 million over two years if it expanded in 2026 under ARPA provisions, equivalent to approximately nine years of net state expansion costs. H.R. 1 eliminated this incentive, reducing the financial attractiveness of expansion compared to pre-July 2025 conditions.
The law also established new federal financing structures that affect expansion economics. Work requirements are now federally mandated rather than requiring state waiver applications. If Kansas expanded today, work requirements would be imposed automatically by federal law, removing the waiver approval uncertainty that complicated previous expansion proposals. The HAWK Act’s work requirement provision aligns with federal mandates rather than exceeding them, though the “proof of employment to enroll” approach differs from monthly 80-hour verification used in other states.
Rural Hospital Crisis: Highest Risk Nationally#
Kansas has the highest percentage of rural hospitals at risk of closure of any state in the nation. This crisis creates both an argument for and against Medicaid expansion, with expansion advocates and opponents interpreting the same hospital vulnerabilities differently.
The Center for Healthcare Quality and Payment Reform identifies 67 of Kansas’s approximately 100 rural hospitals (67%) as at risk of closing, with 30-31 at immediate risk of closure within two to three years. Eight rural hospitals have closed since 2015, with eleven communities losing inpatient care since 2010. The Kansas Hospital Association supports expansion, arguing that covering the uninsured population would reduce uncompensated care costs that strain rural facilities. Hospital systems note that uncompensated care represents a significant burden that expansion would partially alleviate.
Expansion opponents, including Republican legislative leadership, counter that expansion would not solve the fundamental problem of inadequate reimbursement rates and that rural hospitals in expansion states continue to struggle. Senate President Masterson has explicitly argued that expansion has not prevented rural hospital closures in states that expanded, pointing to closures in expansion states as evidence that Medicaid expansion does not stabilize rural healthcare infrastructure.
H.R. 1’s Medicaid cuts affect Kansas’s rural hospitals regardless of expansion status. Rural facilities see reduced Medicaid reimbursements for the populations they currently serve, estimated at a 15% reduction in total rural Medicaid hospital reimbursement under enacted legislation. Disproportionate Share Hospital (DSH) payment reductions, accelerated under H.R. 1, particularly affect Kansas’s safety-net hospitals. The paradox is that declining expansion may not protect rural hospitals from federal Medicaid cuts, while expanding creates new financial obligations for the state during a period of federal funding uncertainty.
KanCare 3.0 Managed Care Infrastructure and Implementation Capacity#
Kansas operates its Medicaid program through KanCare, a managed care model implemented in 2013. The state awarded contracts for KanCare 3.0, effective January 2025 through December 2027, to three managed care organizations: Sunflower Health Plan (Centene subsidiary), UnitedHealthcare Community Plan, and Healthy Blue (Anthem). These MCOs serve the traditional Medicaid population and would be positioned to serve expansion adults if Kansas expanded.
This managed care infrastructure provides a foundation that could support expansion implementation with work requirements, assuming Kansas eventually expands. The MCOs have experience with member engagement, care management, and compliance support systems. However, Kansas would need to build work requirement verification systems from scratch. Unlike states like Georgia or Michigan that developed verification infrastructure during prior implementation attempts, Kansas has no institutional experience with Medicaid work verification beyond SNAP ABAWD requirements operated through a separate agency.
Kansas has extensive experience with SNAP work requirements through its ABAWD (Able-Bodied Adults Without Dependents) program. The state’s Department for Children and Families operates Employment and Training programs requiring 80 hours monthly of work, training, or volunteer activities for SNAP recipients. This infrastructure could theoretically be leveraged for Medicaid work verification if the state expanded coverage with work requirements, creating potential for deemed compliance across programs. Cross-program coordination would reduce duplicative burden but requires system integration that does not currently exist at scale. H.R. 1’s expansion of SNAP work requirements to ages 55-64 and parents with children 14 and older means approximately 5,500 additional Kansans face food assistance work requirements starting November 2025, further stressing coordination systems.
Geographic Implementation Challenges#
Kansas’s geography creates implementation complexity even with managed care infrastructure. The state covers 82,278 square miles across 105 counties, making Kansas the 15th largest state by area. Population concentration in eastern Kansas metropolitan areas (Johnson County Kansas City metro, Sedgwick County Wichita metro) contrasts sharply with western Kansas counties experiencing severe population decline. Clark, Greeley, and Stanton counties each declined more than 15% since 2020, representing frontier conditions with population densities below 6 persons per square mile.
Work requirements assume access to employment, education, training, and community service opportunities that may not exist in frontier Kansas. How does someone in remote Greeley County (population density approximately 2 persons per square mile) find 80 hours monthly of qualifying activities? The nearest community college might be 100 miles away. Job training programs may not exist within reasonable travel distance. Digital verification systems that work in urban Johnson County may fail in western Kansas communities without reliable broadband.
Seasonal employment patterns in agricultural Kansas create additional verification challenges. The state’s wheat, cattle, soybeans, and corn economies create highly seasonal workforce fluctuations. Meatpacking industries in southwest Kansas (Garden City, Dodge City, Liberal) employ large immigrant workforces with varying documentation status. Monthly verification would need to accommodate seasonal patterns or risk disenrolling agricultural workers during off-seasons when work hours naturally decline.
Political Dynamics and the 2026 Election#
Kansas presents a divided political environment. Governor Kelly represents a Democratic governorship in a state that votes Republican at the federal level and maintains Republican supermajorities in the legislature. This dynamic has prevented expansion despite consistent gubernatorial support and public opinion polling showing approximately 72% of Kansans support Medicaid expansion.
The 2026 gubernatorial election may be pivotal. Senate President Masterson’s candidacy positions Medicaid expansion as a potential campaign issue. If Republicans maintain the governorship, expansion becomes increasingly unlikely. A Democratic successor to Kelly would face the same legislative obstacles that have blocked expansion throughout her tenure. Kelly cannot seek reelection due to term limits.
Kansas’s political environment also reflects broader tension between urban and rural interests. Johnson County and the Kansas City suburbs trend more moderate, while rural western Kansas remains strongly conservative. Rural hospital closures create pressure for action, but rural legislators have not translated this pressure into support for expansion. Republican legislators who privately support expansion face primary challenges from the right, creating electoral dynamics where supporting expansion risks more severe political consequences than blocking it.
Looking Forward: Continued Non-Expansion Trajectory#
Kansas will almost certainly remain a non-expansion state through at least 2027, maintaining its coverage gap of approximately 27,000 to 39,000 adults and avoiding the work requirement mandate that applies only to expansion populations. The Republican legislature has consistently blocked expansion despite gubernatorial support, hospital advocacy, public opinion favoring expansion, and the elimination of ARPA financial incentives reducing federal funding available for any future expansion.
The state’s rural hospital crisis will continue regardless of expansion decisions. Kansas hospitals face the highest closure risk nationally, and H.R. 1 Medicaid cuts strain facilities further even without expansion. This crisis may eventually force reconsideration, but legislative action appears unlikely under current political alignment.
If Kansas eventually expands, work requirements will almost certainly be included as compromise to secure Republican support. The HAWK Act framework, with proof of employment for enrollment and exemptions modeled on SNAP, provides the template. However, the state would need to build verification infrastructure from scratch, creating significant implementation risk. Kansas’s existing SNAP work requirement infrastructure offers potential coordination benefits, but coordination opportunity would only be realized if expansion occurs.
The 2026 gubernatorial election represents the most significant near-term variable. A Republican victory would likely close the expansion window indefinitely; a Democratic victory would maintain the possibility but not guarantee legislative success. Kansas demonstrates how state political dynamics can override federal policy incentives, leaving residents in the coverage gap regardless of federal work requirement mandates that would apply if they had coverage.