The One Big Beautiful Bill Act mandates work requirements for Medicaid expansion adults but leaves enormous discretion to states in implementation. By December 2026, approximately 40 states will operationalize work requirements for their expansion populations, and their approaches will differ dramatically. Some states will build systems designed to maintain coverage. Others will build systems that terminate coverage for documentation failures. These choices are not random. They emerge from identifiable political, fiscal, and institutional conditions that vary systematically across states.
Georgia’s Pathways to Coverage demonstrates how a conservative state can implement work requirements with minimal enrollment impact through simplified annual reporting and community partnerships. Arkansas’s 2018 implementation represented the opposite extreme, with monthly online-only reporting that terminated 18,000 people in seven months, primarily among those who were working or qualified for exemptions but could not navigate the verification system. Ohio is building an automation-first approach using data matching to verify compliance without member action. Kentucky faces the impossible task of implementing requirements in Appalachian counties where formal employment barely exists.
Understanding why states choose different approaches requires moving beyond ideology to examine the structural factors shaping implementation decisions. A Republican governor in Ohio faces different constraints than a Republican governor in Mississippi. A state that expanded Medicaid reluctantly operates differently than one that embraced expansion enthusiastically. A state with high administrative capacity can build sophisticated systems that states with legacy technology cannot match.
This article develops a framework for understanding state variation in work requirement implementation, examining the political, fiscal, and institutional variables that predict where states will land on the spectrum from permissive to restrictive. The framework helps stakeholders anticipate state approaches, identify opportunities for influence, and understand why identical federal policy will produce radically different outcomes across states.
The Implementation Spectrum#
State approaches to work requirement implementation cluster into three broad models, though many states will combine elements from multiple approaches.
The zero-friction model prioritizes maintaining coverage over rigorous verification. Georgia exemplifies this approach. After initial technology investments exceeding $100 million failed to produce functional verification systems, Georgia pivoted to simplified annual reporting rather than monthly verification. The state exhausts automated data matching before requiring any member action. Community engagement partnerships replaced technology-centric verification. The result has been minimal enrollment relative to projections but also minimal coverage loss among those enrolled. For Georgia, the implicit calculation is that the political benefit of having a work requirement program outweighs the political cost of aggressive enforcement that produces coverage loss stories.
The enforcement model prioritizes verification rigor over coverage maintenance. Arkansas in 2018 exemplified this approach with monthly reporting deadlines, online-only submission, and immediate termination for non-compliance. The system was designed to identify and remove non-compliant members efficiently. That it removed primarily people who were working or exempt but could not prove it through the specified channels was treated as implementation detail rather than fundamental design failure. States choosing enforcement approaches typically view coverage loss as evidence of policy working as intended rather than system dysfunction.
The automation-first model attempts to balance verification and access through technology. Ohio represents this approach, using unemployment insurance wage data, Social Security disability records, and other administrative databases to verify compliance without requiring member action for most enrollees. Only those whose circumstances cannot be confirmed through data matching enter active verification workflows requiring member submission. This approach assumes that administrative data can substitute for member reporting for most people, limiting documentation burden to the minority whose circumstances are not captured in existing systems.
Most states will implement hybrid approaches combining elements from multiple models. A state might pursue automated verification for employment while requiring active documentation for exemptions. Another might implement zero-friction reporting for most members while maintaining rigorous verification for populations perceived as higher risk of non-compliance. The variation within models may prove as significant as variation across them.
Gubernatorial Politics and Executive Discretion#
Governors shape implementation more than any other single actor. State Medicaid agencies report to governors. Waiver applications reflect gubernatorial priorities. The tone of implementation, whether supportive or punitive, flows from executive direction. Health and Human Services secretaries or Medicaid directors serve at gubernatorial pleasure and implement gubernatorial vision.
Kentucky illustrates gubernatorial influence at its most dramatic. Governor Matt Bevin pursued work requirements aggressively from 2016 to 2019, designing Kentucky HEALTH with monthly premiums, lockout penalties for non-compliance of six months for premium failure and until year-end for work requirement failure, elimination of non-emergency transportation, and removal of vision and dental benefits. CMS projected 95,000 Kentuckians would lose coverage under the full design. When Andy Beshear defeated Bevin in November 2019, running partly on healthcare, he withdrew the waiver within weeks of taking office. Kentucky went from the state most aggressively pursuing work requirements to one that had abandoned them entirely. Now, with federal mandate under OB3 removing gubernatorial discretion to avoid requirements, Beshear’s administration is designing implementation to minimize coverage loss through broad exemptions for parents of children under 13, residents of high-unemployment counties, participants in substance use treatment, and people in disability determination processes. The same state will implement work requirements fundamentally differently depending on which party controls the governor’s mansion.
Georgia presents a different pattern. Republican Governor Brian Kemp could have pursued aggressive enforcement approaches consistent with conservative orthodoxy. Instead, Kemp’s administration accepted the pivot to zero-friction annual reporting after the initial technology-heavy approach failed. The decision reflected pragmatic calculation rather than ideological moderation. Georgia had spent over $100 million on systems that enrolled fewer than 10,000 people. Aggressive enforcement that produced coverage loss stories would draw negative attention to a program that was already struggling. The zero-friction approach allowed Kemp to maintain a work requirement program, claim policy success, and avoid media coverage of working Georgians losing healthcare due to paperwork failures. The political benefit came from having the program, not from enforcing it rigorously.
Yet gubernatorial influence operates within constraints. The Republican legislature in Kentucky passed work requirement legislation that Beshear vetoed, then overrode his veto. The state is now legally required to pursue implementation regardless of gubernatorial preference. Divided government creates tension between what governors want and what they can achieve. North Carolina’s Democratic governor faces a Republican legislature that may push for more restrictive implementation than the executive branch would choose independently. Wisconsin presents similar dynamics, with a Democratic governor (or potentially Republican successor after 2026) implementing requirements that the Republican legislature supported over executive objection.
Gubernatorial transitions create policy uncertainty. Kentucky’s Beshear cannot run for reelection in 2027 under term limits. The gubernatorial race will determine whether Kentucky continues minimizing harm or shifts to more aggressive enforcement. Michigan’s succession from Gretchen Whitmer will shape whether that state maintains its human-centered design approach. Arizona, Ohio, and other states face gubernatorial elections that could shift implementation philosophy mid-stream.
Party matters, but less than ideology might suggest. Georgia’s Republican Governor Brian Kemp chose a zero-friction approach that prioritizes administrative simplicity over enforcement rigor. His calculation appeared to be that having a work requirement program was politically valuable, but creating coverage loss stories was not. Republican governors in states with vulnerable expansion populations may reach similar conclusions. The political benefit of work requirements as policy may not require aggressive enforcement as practice.
The role of health agency leadership matters within gubernatorial administrations. Medicaid directors and HHS secretaries translate gubernatorial priorities into policy detail. An aggressive Medicaid director can push enforcement within a moderate administration; a cautious director can soften implementation within a restrictive administration. These second-tier appointments often receive less attention than gubernatorial races but shape implementation significantly. States where Medicaid directors have healthcare backgrounds may approach requirements differently than states where directors come from welfare administration or fiscal management backgrounds.
State Fiscal Conditions and Medicaid Economics#
Fiscal constraints shape what states can build and what they’re motivated to achieve. Work requirement implementation requires technology investment, staff hiring, call center capacity, and navigation infrastructure. States vary dramatically in their capacity to fund these systems.
High-capacity states can build sophisticated verification systems with multiple submission channels, real-time data matching, integrated navigation support, and robust appeals processes. New York, California, and Massachusetts have state budgets, technology infrastructure, and administrative expertise to implement complexity well. These states can afford to build portals with mobile optimization, establish call centers with adequate staffing, develop data matching interfaces with multiple external systems, and create appeals processes that provide meaningful review. Whether they will invest in such systems is a political question, but whether they can is not in doubt.
Low-capacity states face structural constraints. Mississippi, West Virginia, and many rural states have legacy eligibility systems built in the 1990s or earlier, insufficient IT staff to maintain existing systems let alone build new ones, and budget limitations that prevent significant new investment. These states may implement crude systems not because they prefer them but because they cannot build anything else. The result may be implementation failures regardless of policy intent. Arkansas’s online-only portal in 2018 reflected technology limitations as much as policy choice; the state simply did not have the infrastructure to offer phone or in-person reporting at launch.
The state fiscal picture in late 2025 is mixed. Federal pandemic relief funds have largely been spent. Some states face budget surpluses from strong economic performance; others face deficits from tax cuts or revenue shortfalls. States with budget constraints will struggle to fund the administrative buildout work requirements demand, potentially forcing choices between minimal systems that fail populations and delayed implementation that draws federal scrutiny.
The vendor market partially homogenizes state approaches. States that cannot build systems in-house purchase from vendors like Deloitte, Accenture, Conduent, and smaller Medicaid technology specialists. These vendors offer products developed for other states, modified for local requirements. States buying the same products may implement similar systems despite different political preferences. Georgia’s reliance on Deloitte shaped what was possible to build, and the vendor’s limitations contributed to the technology failures that drove Georgia toward simplified approaches.
Vendor concentration creates risk. A handful of large vendors dominate the Medicaid technology market. If multiple states simultaneously pursue procurement from the same vendors, capacity constraints may emerge. Vendors building for Ohio may not have bandwidth to simultaneously build for Michigan. States that entered procurement early secured vendor attention; states entering late face capacity constraints.
State fiscal incentives cut in competing directions on verification investment. States receive enhanced federal matching for Medicaid expansion populations at 90 percent federal share, meaning every dollar spent on expansion enrollees’ healthcare costs the state only ten cents. Work requirement implementation costs, however, come largely from administrative budgets with standard 50 percent matching rates for most administrative functions. Building expensive verification systems requires significant state investment that serves a population where federal funds cover most service costs. The fiscal logic favors simple systems over elaborate ones: why should states spend substantial administrative dollars to verify eligibility for programs where the federal government pays most costs?
Yet states also face fiscal pressure to reduce enrollment. Work requirements that terminate coverage shift costs away from state budgets even at enhanced matching rates. Ten percent of nothing is less than ten percent of something. For states hostile to expansion, work requirements offer a mechanism to reduce enrollment without formally reversing expansion. Louisiana under Republican Governor Jeff Landry has discussed work requirements as a pathway to enrollment reduction. Georgia’s Pathways program, while not aggressive in enforcement, restricts eligibility to 100 percent of poverty rather than the 138 percent full expansion would provide.
The fiscal incentive to reduce enrollment competes with the fiscal disincentive to invest in verification infrastructure. States that want enrollment reduction must invest in systems capable of achieving it; states that don’t want reduction have no incentive to build effective enforcement systems. This fiscal logic suggests that states hostile to expansion may paradoxically build more capable verification systems than states supportive of expansion, because only hostile states have fiscal motivation to make requirements bite.
Medicaid Expansion History and Political Investment#
How states came to Medicaid expansion shapes how they implement work requirements on expansion populations. States that expanded enthusiastically have political investment in expansion success. States that expanded reluctantly or through ballot initiatives may have legislatures hostile to the populations now facing work requirements.
Ballot initiative states present distinctive dynamics. Utah, Idaho, Nebraska, Missouri, and Oklahoma expanded Medicaid through voter initiatives over legislative opposition. Those legislatures now control implementation of requirements on populations they never wanted to cover. The political dynamic is one of hostile implementation: legislatures implementing policy on populations they opposed covering. This creates risk of restrictive approaches designed to reduce enrollment that legislators never supported.
Missouri illustrates the tension. Voters approved Medicaid expansion in 2020 with 53 percent support. The Republican-controlled legislature responded by refusing to appropriate funds for expansion, leading to court orders requiring implementation. Now that same legislature will shape work requirement implementation for the expansion population. Whether legislative hostility to expansion translates to punitive verification systems remains to be seen, but the political dynamic differs fundamentally from states where expansion had bipartisan support.
Late expansion states face compressed timelines. North Carolina expanded in 2023, meaning the state must build work requirement infrastructure from scratch while still stabilizing initial expansion enrollment. There is no existing verification system to adapt, no prior experience to learn from, and no established relationships between state agencies and expansion populations. Everything must be built by December 2026. The timeline pressure may force North Carolina toward simpler approaches regardless of policy preference.
Non-expansion states present a different context entirely. The twelve states that never expanded Medicaid do not face the same December 2026 deadline for work requirements on expansion populations because they have no expansion populations. Texas, Florida, and other holdout states may use work requirements as the price of future expansion, similar to Georgia’s Pathways approach of partial expansion with work conditions. For these states, work requirements are an entry ticket to expansion rather than a condition added to existing coverage.
Administrative Capacity and Technology Infrastructure#
State administrative capacity determines what implementation is achievable within the fourteen-month window before December 2026. Capacity differences across states may prove more important than policy preferences in determining outcomes.
State-administered versus county-administered Medicaid creates different implementation challenges. Ohio administers Medicaid through 88 county Job and Family Services offices, creating potential for 88 different implementation experiences. California’s county-administered system creates 58 variations. New York’s county administration outside New York City adds complexity. County-administered states face coordination challenges that state-administered systems avoid, but they also have local relationships and community knowledge that centralized systems lack.
Technology infrastructure varies dramatically. States with modern integrated eligibility systems can add work requirement modules relatively easily. States with legacy systems face fundamental architectural challenges. Building real-time data matching requires API connections to employment databases, educational institutions, and other systems that older technology cannot support. The 10-month timeline is insufficient for major system replacements, forcing states to work within existing technology limitations.
Procurement timelines matter. States requiring formal RFP processes for vendor selection need six to twelve months for selection and contracting alone, leaving minimal time for development and testing. Emergency procurement authority or sole-source contracts to vendors with proven systems accelerate timelines but raise cost and oversight concerns. States that have not already begun procurement face severe timeline pressure.
Workforce capacity affects implementation quality. Eligibility workers must be trained on new requirements, exemption processes, and verification systems. Call centers must be staffed to handle member inquiries. Appeals must be processed within legal timeframes. States facing hiring freezes, worker shortages, or high turnover will struggle to build the human capacity work requirements demand, regardless of what their technology can do.
Regional Patterns and Political Culture#
State approaches cluster geographically, reflecting regional political cultures, shared administrative traditions, and cross-state learning. Political scientists have long observed that American states develop distinctive political cultures that persist across decades and shape policy choices. Daniel Elazar’s classic typology of traditionalistic, moralistic, and individualistic political cultures maps roughly onto regional patterns, though the mapping is imperfect and contested.
Appalachian states face common challenges of job scarcity, transportation barriers, and concentrated health burdens from the opioid epidemic and legacy industries like coal mining. Kentucky, West Virginia, Ohio’s southeastern counties, Virginia’s southwestern counties, and Tennessee’s eastern regions share circumstances that make work requirements structurally problematic. Requiring employment verification in communities where formal employment barely exists is not behavioral intervention; it is administrative pathway to coverage loss.
The economic devastation of Appalachia is not temporary or cyclical. Coal employment collapsed from hundreds of thousands of jobs to under 50,000 nationally, with most remaining jobs in Wyoming and Montana rather than the traditional coal states of Kentucky, West Virginia, and Pennsylvania. The labor force participation rate in eastern Kentucky counties is among the lowest in the nation. Disability income is the primary household support in many communities. Intergenerational poverty means entire families have never had formal employment that would generate the pay stubs and W-2s that verification systems assume.
These states may develop common approaches to geographic exemptions or county-level variations that acknowledge economic reality. Kentucky’s waiver application includes provisions for counties with unemployment rates exceeding 150 percent of the state average. West Virginia faces similar pressures. The question is whether federal regulators will approve geographic accommodations that effectively exempt significant portions of state populations.
Deep South states share traditions of restrictive welfare administration and limited Medicaid generosity that trace to the Jim Crow era and the racial politics of poverty programs. Georgia’s partial expansion to 100 percent of poverty rather than the full 138 percent reflects this tradition, as does the state’s emphasis on work requirements as the price of any expansion. Alabama, Mississippi, and Texas have not expanded at all.
States in this region implementing work requirements may favor enforcement approaches consistent with historical patterns. The welfare reform era produced particularly aggressive implementation in Southern states, with higher sanction rates and lower exemption rates than other regions. Whether this pattern continues with Medicaid work requirements remains to be seen, though Georgia’s zero-friction evolution suggests pragmatic considerations can override regional tradition when implementation failure becomes embarrassing.
Upper Midwest states share manufacturing heritage and pragmatic political cultures that historically crossed party lines. Michigan, Wisconsin, Ohio, and Minnesota have traditions of moderate approaches to social policy that combine support for safety net programs with expectations of work and contribution. The progressive era reforms that created much of American social policy had roots in Midwestern reform movements.
These states may implement work requirements with less ideological intensity than Southern or Mountain West states, focusing on administrative efficiency and member support rather than behavioral transformation or punishment. Ohio’s automation-first approach reflects this pragmatic tradition: the goal is accurate verification with minimal burden, not signaling commitment to work as moral value. Michigan’s brief 2020 implementation emphasized human-centered design in communications, attempting to make requirements navigable rather than emphasizing enforcement.
Mountain West states combine rural isolation, significant tribal populations, and libertarian political traditions that create distinctive implementation challenges. Arizona, New Mexico, Nevada, Idaho, and Montana face geographic barriers that make verification systems designed for urban populations structurally inappropriate. The drive to a county office may be 100 miles. Broadband access is limited. Employment opportunities concentrate in a few urban areas while vast territories have minimal formal economy.
Tribal sovereignty considerations require coordination with tribal governments that complicates state administration. Native Americans represent significant portions of state populations in Arizona (5%), New Mexico (11%), Montana (7%), and South Dakota (9%). Federal Indian law creates distinctive legal frameworks. Tribal governments may choose to administer verification for their members under agreements with states, or states may need to accommodate tribal employment and community structures that do not fit standard verification categories.
Border states face cross-border workforce dynamics that complicate verification. Workers living in one state may be employed in another. Commuting patterns cross state lines in metropolitan areas like Kansas City, St. Louis, Philadelphia, Cincinnati, and the Washington D.C. region. A Maryland resident working in the District of Columbia, a Kansas resident working in Missouri, or a New Jersey resident working in Pennsylvania presents verification challenges that single-state systems do not naturally accommodate.
States must coordinate verification across jurisdictions or accept that cross-border employment complicates documentation. Interstate data sharing agreements may help, but these agreements take time to negotiate and implement. The December 2026 deadline does not provide adequate time for comprehensive interstate coordination.
Political Environment and Legislative Dynamics#
The interaction between governors, legislatures, and state agencies shapes implementation within each state. Unified government produces different outcomes than divided government. Legislative involvement in implementation detail varies by state tradition.
Unified Republican government typically produces more restrictive approaches. States where Republicans control both legislative chambers and the governorship face fewer internal constraints on enforcement-oriented implementation. Indiana’s history of conditionality requirements in HIP 2.0 reflects unified Republican capacity to pursue work-focused approaches.
Unified Democratic government typically produces more permissive approaches. States with Democratic control may implement work requirements with maximal exemptions, generous good cause provisions, and emphasis on support rather than enforcement. These states must still comply with federal requirements but have latitude in how strictly to verify compliance.
Divided government creates negotiation. When governors and legislatures of different parties share power, implementation reflects compromise. Kentucky’s Democratic governor implements requirements that the Republican legislature mandated over his veto. The result may be implementation that satisfies neither side fully but reflects political balance.
Legislative micromanagement varies by state. Some legislatures specify implementation details in statute, constraining executive discretion. Others delegate to agencies, allowing governors and Medicaid directors to shape implementation through administrative channels. Where legislatures specify details, political dynamics are embedded in law. Where agencies have discretion, implementation can shift with executive leadership.
Predicting State Approaches#
The variables examined here interact to produce state-specific predictions about implementation approaches. A predictive framework considers:
Party control matters but is not deterministic. Republican states generally pursue more restrictive approaches, Democratic states more permissive, but Georgia’s zero-friction approach demonstrates that conservative states can prioritize administrative simplicity. The correlation between party control and implementation strictness is real but imperfect.
Prior experience strongly predicts future choices. States with failed implementations are unlikely to repeat approaches that generated coverage losses and litigation. Arkansas’s 2025 proposal differs fundamentally from its 2018 approach. Kentucky’s Beshear administration designs to avoid Bevin-era failures. States learning from others’ experiences may skip the enforcement model entirely.
Administrative capacity constrains options. States with limited technology and workforce cannot implement sophisticated systems regardless of preference. Low-capacity states may implement simple approaches by necessity rather than choice.
Fiscal conditions shape investment. Wealthy states can build elaborate systems; poor states cannot. States under budget pressure may minimize administrative investment, leading to simpler systems.
Population size determines feasibility. Ohio cannot manually verify 700,000 expansion adults. Large states require automation. Small states like South Dakota can implement relationship-based approaches that large states cannot scale.
Geographic distribution matters. States with rural dominance face different challenges than those with urban concentration. Systems designed for metropolitan areas fail in rural contexts.
Advocacy ecosystems influence choices. States with strong progressive advocacy face more pressure for permissive implementation. States with strong conservative advocacy face pressure for enforcement. The advocacy balance shapes political calculations.
Litigation risk enters calculations. States aware of Stewart v. Azar and related precedents may design to minimize legal vulnerability. Due process protections, accessible verification, and good cause exceptions reduce litigation risk but add complexity.
The 50-State Laboratory#
American federalism is often described as a laboratory of democracy, with states experimenting and learning from each other. Work requirement implementation will test this theory. Forty states implementing the same federal mandate with different approaches creates natural variation that will produce evidence about what works and what fails.
The laboratory metaphor has limits. Unlike controlled experiments, state implementations occur in dynamic systems where choices interact. Georgia’s approach works partly because Georgia implemented early and learned from failures. States implementing in December 2026 face different conditions. Cross-state learning requires time that the compressed timeline does not provide.
Yet real learning is possible. States pursuing automation-first approaches like Ohio will generate evidence about data matching effectiveness and the populations data matching misses. States pursuing zero-friction approaches like Georgia will generate evidence about enrollment levels and compliance rates under simplified verification. States pursuing enforcement approaches will generate evidence about coverage losses and their demographics. This evidence base will inform future policy even if it cannot shape initial implementation.
The risk is that the laboratory produces harm before producing knowledge. Arkansas’s 2018 experiment generated robust evidence that work requirements cause coverage loss without increasing employment, but it generated that evidence by terminating 18,000 people’s healthcare. The question for December 2026 is whether states learn from Arkansas before replicating its failures.
Framework for Stakeholders#
For stakeholders seeking to influence or anticipate state approaches, the political economy framework suggests several strategies.
Identify the determining variables in each state. Which factors matter most for the state you are analyzing or trying to influence? In Kentucky, gubernatorial politics and Appalachian geography dominate. In Ohio, administrative capacity and population size drive toward automation. In Missouri, ballot initiative history and legislative hostility shape dynamics. Understanding which variables matter most focuses intervention.
Recognize structural constraints. Some factors cannot be changed on implementation timelines. State administrative capacity will not transform in fourteen months. Technology infrastructure will not modernize before December 2026. Advocacy that ignores constraints wastes resources on impossibilities.
Target discretionary choices. Within structural constraints, states retain significant discretion. Exemption breadth, good cause definitions, reporting frequency, verification channels, and sanction structures are all subject to state choice. Advocacy that focuses on achievable changes within existing constraints is more likely to succeed.
Build coalitions across interests. MCOs have financial interest in enrollment stability. Providers have interest in paying patients. Employers have interest in minimizing documentation burden. These interests may align with coverage maintenance even when ideological interests diverge. Coalition building that connects interests across stakeholder categories may influence implementation where ideological advocacy fails.
Plan for variation. National organizations operating across states must develop differentiated strategies. The approach that works in Michigan will not work in Mississippi. State-specific analysis requires state-specific strategies.
Anticipate iteration. Initial implementation will not be final implementation. States will learn from experience, face litigation, respond to coverage loss data, and adjust. Advocacy that prepares for post-launch engagement may prove more influential than advocacy focused solely on initial design.
Conclusion#
The political economy of state variation in work requirement implementation reflects the complexity of American federalism. Identical federal mandates produce radically different state approaches because states differ in political leadership, fiscal capacity, administrative infrastructure, expansion history, regional culture, and stakeholder dynamics. Understanding these differences helps stakeholders anticipate outcomes, plan strategies, and identify opportunities for influence.
The framework developed here applies beyond work requirements to any federal policy implemented through state discretion. The variables that predict work requirement approaches predict Medicaid policy generally and illuminate the political dynamics shaping healthcare access in American federalism.
For the 18.5 million expansion adults facing work requirements by December 2026, these political economy dynamics will determine whether they navigate systems designed to maintain coverage or systems designed to identify non-compliance. The variation across states will produce variation in coverage outcomes. Where someone lives will shape whether they keep their healthcare, not because their work effort differs but because the systems they navigate differ.
The 50-state laboratory begins its experiment in December 2026. The evidence it generates will shape American healthcare policy for decades. The question is how many people will lose coverage while that evidence accumulates.