Governor Kevin Stitt stood before a joint session of the Oklahoma legislature on February 2, 2026, his hand visibly bandaged from a cooking accident, and delivered a metaphor that captured six years of frustration. “Government dependency is a trap,” he said. “It robs self-reliance and balloons budgets. I always say government programs should be a trampoline, not a hammock, but too often that is not the case. Medicaid is Exhibit A, driving massive spending growth while enabling waste.” Stitt then called on lawmakers to send a question to voters that would “allow adjustments” to Medicaid expansion, the same program Oklahoma voters had enshrined in the state constitution just five years earlier specifically to prevent him from doing what he was now asking to do.
The term-limited governor did not specify what those adjustments would entail. He did not need to. The 2026 legislative session had already produced SB 1547, introduced by Senator Christi Gillespie of Broken Arrow, conditioning Medicaid eligibility for adults aged 19 to 64 on fulfilling 80 hours monthly of work requirements effective January 1, 2027. Representative Mark Lepak of Claremore had filed HB 3599 imposing a $35 cost-sharing requirement per provision of care for expansion enrollees, and HB 3602 addressing provider tax changes. House Speaker Kyle Hilbert of Bristow said he supported the governor’s call, noting that the Oklahoma Health Care Authority’s budget request had reached nearly $2 billion with increasing utilization from both traditional and expansion populations.
The Oklahoma Hospital Association responded within hours. Rich Rasmussen, the association’s president and CEO, called Medicaid expansion a “cost-efficient system” and said that since voters approved it in 2020, the state’s national health ranking had improved, the uninsured rate had dropped, and maternal morbidity outcomes now ranked among the best in the nation. “Limiting it,” he said, “would undermine care for all Oklahomans.”
Oklahoma’s work requirement story is unlike any other state’s. It involves a constitutional amendment designed to prevent work requirements, a governor who spent his entire tenure trying to impose them, a federal law that now mandates them, a legislative session generating bills to enforce them, and a tribal population comprising 17 percent of the state’s Medicaid enrollment that is exempt from them entirely. Each of these forces pulls in a different direction. Where they converge will define what 220,000 expansion adults experience when the compliance clock starts.
The Constitutional Collision#
Oklahoma became the first state to expand Medicaid through a constitutional amendment when voters approved State Question 802 on June 30, 2020, by a margin of 50.45 percent. The initiative’s drafters had studied what happened in Maine, Nebraska, Idaho, and Utah, where governors and legislatures attempted to undermine voter-approved expansions by attaching work requirements, premiums, and other restrictions. They chose constitutional language that would require another statewide referendum to modify.
Section 2(B) of Article XXV-A states that “No greater or additional burdens or restrictions on eligibility or enrollment shall be imposed on persons eligible for medical assistance pursuant to this Article than on any other population eligible for medical assistance under Oklahoma’s Medicaid program.” The provision was aimed directly at SoonerCare 2.0, Governor Stitt’s March 2020 proposal that would have implemented partial expansion with community engagement requirements, per-capita spending caps, and premiums. Stitt had attended a press conference with CMS Administrator Seema Verma in January 2020 announcing federal support for state flexibility in imposing work requirements. Voters foreclosed that path seven months later.
The legislature’s response was hostile from the start. Republican lawmakers refused to fund expansion. Enrollment began only in July 2021 after court orders forced implementation. Stitt’s administration had also submitted a Section 1115 waiver in December 2018 seeking work requirement authority, proposing 20 hours per week for non-exempt enrollees aged 19 to 50. The waiver estimated that of 102,000 SoonerCare enrollees in the target age range, roughly 6,000 would actually be subject to requirements after exemptions. That calculation was based on pre-expansion enrollment. The universe changed entirely when 237,000 expansion adults joined the program.
H.R.1 overrides the constitutional protection through federal supremacy. The state constitution prohibits Oklahoma from voluntarily imposing additional burdens, but it cannot prevent compliance with a federal mandate. Oklahoma must implement 80-hour monthly work requirements for expansion adults by December 31, 2026, regardless of what its constitution says about additional eligibility burdens. The practical question is whether the constitutional language constrains how Oklahoma implements: whether the state must pursue the most accommodation-oriented approach available under federal law, or whether the Supremacy Clause renders the anti-burden provision entirely inoperative.
No court has addressed this question. The Oklahoma Attorney General has not issued a formal opinion. But the 2026 legislative session’s aggressive bill filings suggest that Republican lawmakers believe the constitutional protection is functionally dead, at least regarding work requirements. The proposed state question to “allow adjustments” would formalize that conclusion, giving voters the opportunity to either reaffirm or repeal the protections they approved in 2020.
H.R.1 and Federal Requirements#
H.R.1 requires 80 hours monthly of work, education, job training, job search, community service, or caregiving for expansion adults aged 19 to 64. Oklahoma must verify compliance at application and semi-annual redetermination. CMS issued initial guidance on December 8, 2025, with detailed regulations expected by June 1, 2026. The compliance deadline is December 31, 2026, with good-faith extensions available through December 31, 2028.
Exemptions cover pregnancy through 60 days postpartum, medical frailty, disability, full-time students, caregivers of dependents under 14 or incapacitated individuals, unemployment benefit recipients, and substance use disorder treatment participants. Critically for Oklahoma, the law exempts American Indians and Alaska Natives who are eligible for services through the Indian Health Service. The mandatory outreach period runs from June 30 through August 31, 2026.
The Oklahoma Health Care Authority estimated that approximately 126,000 working-age expansion adults will be subject to community engagement requirements, roughly half the expansion population. The remainder qualifies for exemptions including AI/AN status, age, pregnancy, disability, and other protected categories. OHCA has indicated the state faces approximately $30 million in additional administrative costs for implementation. The agency also noted that reduced enrollment could offset long-term costs, a framing that implicitly acknowledges expected coverage losses.
The Tribal Dimension#
No state’s work requirement implementation intersects tribal sovereignty as significantly as Oklahoma’s. Thirty-nine federally recognized tribes are headquartered in the state, including the Cherokee, Chickasaw, Choctaw, Muscogee (Creek), and Seminole nations. As of May 2025, 182,494 American Indian and Alaska Native individuals were enrolled in SoonerCare, representing 17 percent of total Medicaid enrollment, by far the highest concentration in any expansion state.
H.R.1’s AI/AN exemption, secured through sustained advocacy by the National Indian Health Board and tribal health organizations, means these 182,494 enrollees are not subject to work requirements. This is not merely a population carve-out. It reshapes the entire implementation landscape. When nearly one in five Medicaid enrollees is exempt by category, the administrative system processes a fundamentally different denominator. The 126,000 estimate of affected individuals already accounts for this exemption, but the operational implications extend beyond headcount.
AI/AN members in Oklahoma have a distinctive relationship with managed care. Under the SoonerSelect transition that took effect in April 2024, AI/AN members can voluntarily opt in to managed care plans but cannot be mandated to enroll. Those who do not opt in remain in traditional fee-for-service SoonerCare. This creates a dual-track system where the MCO infrastructure being developed for work requirement navigation may not reach AI/AN members who remain in fee-for-service, even though those members do not need work requirement navigation because they are exempt. The administrative architecture must accommodate both tracks without creating confusion about who is subject to what.
Tribal health systems, including Indian Health Service facilities and tribally operated clinics, serve as primary care providers for much of the AI/AN population. These facilities also serve non-AI/AN patients in communities where they represent the only available healthcare access point. If work requirements cause coverage losses among non-AI/AN expansion adults in areas served by tribal health facilities, those facilities absorb increased uncompensated care from a population they were not designed to serve at that volume.
The interaction between tribal sovereignty, managed care opt-in structures, work requirement exemptions, and community healthcare access creates a policy environment unique to Oklahoma. Implementation planning must navigate federal Indian law, state Medicaid administration, MCO contract design, and tribal consultation requirements simultaneously.
Geographic and Economic Terrain#
Oklahoma’s 77 counties span an enormous range of economic conditions. The Oklahoma City and Tulsa metropolitan areas, home to roughly 60 percent of the state’s population, offer diversified employment markets where most expansion adults have access to jobs that meet the 80-hour threshold. The aerospace industry in Oklahoma City, the energy sector’s corporate headquarters in both cities, and growing healthcare and technology sectors create employment environments where work verification is relatively straightforward.
The rest of the state presents a different picture. Western Oklahoma’s economy depends on oil, gas, and agriculture, three sectors defined by volatility. When oil prices drop, as they periodically do, employment in the Permian Basin and Anadarko Basin fields contracts rapidly. Workers who were easily meeting work requirements in one quarter may be scrambling for hours the next. Agricultural employment in the panhandle and western counties follows seasonal patterns that may not align with monthly verification windows. A wheat farmer in Texas County who works 60-hour weeks during harvest and near-zero hours in winter averages well above 80 hours monthly but fails verification during low-activity months.
The panhandle region represents Oklahoma’s most extreme compliance challenge. Cimarron County has experienced population decline and has essentially no social service infrastructure beyond what can be accessed in Guymon or Liberal, Kansas. The distance from Boise City in the panhandle to Broken Bow in the southeast exceeds 500 miles. A state policy designed in Oklahoma City must function across that span, in communities where broadband access is limited, employment is often informal, and the nearest DHS Human Services Center may be an hour’s drive.
Southeast Oklahoma, encompassing the Choctaw Nation’s territory and some of the state’s poorest counties, combines high Medicaid enrollment with limited employment opportunity and significant tribal presence. McCurtain, Pushmataha, and LeFlore counties have poverty rates above 25 percent and healthcare access challenges that Medicaid expansion partially ameliorated. Coverage losses from documentation failure in these counties would fall on populations with the fewest alternative coverage options and the most fragile healthcare infrastructure.
Rural Hospital Fragility#
Oklahoma’s rural healthcare system cannot absorb significant coverage losses. Nine rural hospitals have closed since 2005. According to a 2025 analysis, 59 percent of remaining rural facilities operate at a loss. The Healthy Minds Policy Initiative warned that cuts to Medicaid could mean a loss of $8.7 billion for Oklahoma hospitals over the next decade, with rural hospitals facing $5.13 billion in losses during that period. While Oklahoma could access the federal Rural Health Transformation Fund to offset some losses, those grants are typically short-term while Medicaid payment cuts would be permanent.
Oklahoma’s provider tax structure adds another dimension. The Supplemental Hospital Offset Payment Program taxes hospitals and uses collected fees to draw down additional federal matching funds that are redistributed to participating hospitals. The assessment rate increased to the maximum 4 percent in 2024. Critical-access hospitals are exempt from the tax but receive enhanced directed payments through SoonerSelect. Work requirements that reduce enrollment would decrease the revenue base for SHOPP, potentially affecting the redistributed payments that support the very rural hospitals most vulnerable to coverage loss impacts.
Representative Trey Caldwell of Faxon has filed HB 3975 addressing the Rural Health Transformation Fund, seeking to ensure Oklahoma maximizes access to the $50 billion federal allocation. But the fund was designed to offset provider tax and directed payment restrictions in H.R.1, not to compensate for enrollment losses from work requirements. Rural hospitals face exposure from both directions simultaneously.
The SoonerSelect Infrastructure#
Oklahoma’s April 2024 transition to managed care through SoonerSelect provides infrastructure that other states implementing work requirements do not have. Three MCOs serve the expansion population: Aetna Better Health of Oklahoma (a CVS Health subsidiary), Humana Healthy Horizons of Oklahoma, and Oklahoma Complete Health (a Centene subsidiary). The initial SoonerSelect contracts were valued at $3.75 billion for the first 15-month period.
Oklahoma Complete Health, as the Centene subsidiary, has demonstrated member engagement capacity through its SDOH referral programs, reporting over 11,000 social determinants referrals in 2024, and member reward systems that incentivize preventive care utilization. These capabilities could be redirected toward work requirement compliance support, helping members identify qualifying activities, document hours, and navigate exemption processes.
The managed care transition is still young, however. SoonerSelect began enrollment less than two years ago, and the system is still maturing operationally. Adding work requirement verification responsibilities to MCO contracts while the managed care infrastructure itself remains in its developmental phase creates execution risk. MCOs that are still building provider networks, refining care coordination protocols, and establishing member communication systems must simultaneously develop compliance navigation capabilities they have never been asked to provide.
The conflict-of-interest provisions in H.R.1 further complicate MCO involvement. Plans cannot conduct compliance determinations if they have financial interest in the outcomes. Since MCOs lose revenue when members lose coverage, they cannot serve as neutral arbiters of work requirement compliance. But they can, and financially should, invest in navigation services that help members demonstrate existing compliance. The boundary between prohibited determination and permitted navigation will be drawn by CMS guidance and state implementation choices.
What Oklahoma Will Likely Do#
Oklahoma’s implementation will be shaped by the tension between a governor and legislative majority that want aggressive enforcement and a constitutional provision that, even if functionally superseded by federal law, creates legal and political context favoring measured approaches. The resolution depends on timing. Stitt leaves office in January 2027. If the constitutional amendment question reaches voters before then and passes, the next governor inherits unrestricted authority. If it does not, the anti-burden language remains in the constitution, potentially constraining how enthusiastically Oklahoma can enforce requirements beyond the federal minimum.
The most likely near-term trajectory includes passage of SB 1547 implementing work requirements as H.R.1 mandates, reliance on SoonerSelect MCOs for member outreach and navigation support, significant AI/AN exemption processing given the size of the tribal population, and utilization of the good-faith extension to December 2028 if systems are not ready by the initial deadline.
Coverage loss projections from KFF estimate that as many as 174,000 Oklahomans could lose coverage due to the combined effects of H.R.1’s provisions. Work requirements alone will affect a subset of that number, but the interaction of work requirements with semi-annual redetermination, the $35 cost-sharing proposal, and provider tax restrictions creates compounding exposure. The populations most likely to lose coverage are those working informally in rural areas, those cycling between employment and unemployment in the energy sector, and those with complex medical or social circumstances who qualify for exemptions but cannot document them.
House Minority Leader Cyndi Munson of Oklahoma City, who is running for governor in 2026, expressed the opposition view: “The governor clearly has a misunderstanding, is so disconnected from what everyday folks are going through that he doesn’t understand what’s happening in healthcare across the state.” Whether the next governor shares Stitt’s trampoline-and-hammock philosophy or Munson’s concern for struggling families will determine whether Oklahoma interprets its remaining implementation discretion toward enforcement or accommodation.
What will not change is the federal mandate itself, the tribal exemption that shields nearly a fifth of SoonerCare enrollment, or the rural hospital fragility that makes large-scale coverage losses a healthcare infrastructure crisis rather than merely an enrollment statistic. Oklahoma’s constitution was designed to prevent exactly this scenario. Federal law made it happen anyway. The question now is whether the state will build compliance systems that recognize the work its expansion adults already do, or verification systems that catch those who cannot prove it.