Washington state is preparing to implement federal Medicaid work requirements by Jan. 1, 2027. But the state’s public response so far has not focused on helping recipients find work. Much of its energy has centered on an automatic verification system that will use existing records to determine whether recipients meet the requirement or qualify for an exemption, reducing the paperwork required of many recipients.
Under H.R. 1, certain Medicaid recipients between ages 19 to 64 generally must complete at least 80 hours per month of employment, community service, participation in a work program or another qualifying activity — or attend school at least half time. It’s a welcome change that could help bring more self-sufficiency and forward motion in individuals’ lives.
Apple Health — what the state has named its Medicaid program — covers nearly 2 million Washington state residents. Around 600,000 of those recipients are adults in the Affordable Care Act’s Medicaid expansion group who could be affected by the work requirement. (The requirement does not apply to children or people who qualify for Apple Health through traditional Medicaid categories such as pregnancy or federally recognized disability.)
That doesn’t mean all 600,000 expansion adults will need to find jobs. Some already satisfy the work requirement, while others will qualify for an exclusion or exemption. Numerous exclusions and exemptions are available for certain parents and caregivers, American Indians and Alaska Natives, veterans with total disability ratings and medically frail individuals, among others.
Washington state’s Health Care Authority, which manages Medicaid in the state, is building a verification hub that will use existing employment, education, public-benefit and medical information to determine whether recipients have satisfied the requirement or qualify for an exemption. State officials estimate that the system could automatically verify approximately 400,000 of the roughly 600,000 Washington residents potentially affected.
Automatic verification can make it easier to remain eligible for Apple Health, but it does not help someone who is not working obtain employment, enroll in training or begin another qualifying activity. The hub is a legitimate compliance tool — but it’s not an employment service. The Health Care Authority’s public materials and the governor’s press communications also do not identify any expansion of Medicaid-specific employment, job-placement or training services, even though Washington has high unemployment and more than 600,000 adults in Medicaid expansion.
Minimizing the requirement’s effect rather than embracing its purpose describes what’s happening in our state.
Washington also plans to allow recipients to self-attest their income, employment or exemption status throughout 2027 when electronic records cannot verify compliance. Federal rules permit self-attestation during the first year, but the decision to allow self-attestation of employment during 2027 raises legitimate questions about program integrity, subsequent auditing and how the state will address false or inaccurate statements. Past Medicaid audits are not encouraging. A 2024 state performance audit found that the state made an average of about $8.6 million a year in unnecessary managed-care premium payments for people concurrently enrolled in Medicaid in Washington and at least one of the seven other states examined. Those payments did not provide clients with additional care, but they did cost taxpayers. The state Legislature also seemed unconcerned about a fix. I hope the twice-yearly Medicaid eligibility determinations required by H.R. 1 will help identify at least some of these concurrent enrollments.
Ticked-off Bob
Gov. Bob Ferguson has made clear that his administration is implementing H.R. 1 under protest. At his Sept. 3 press conference, Ferguson described the federal changes as “morally bankrupt” and said it “really ticks me off” that the state must respond to them. The state has little practical choice: Failure to implement federal Medicaid requirements could put federal Medicaid funding at risk.
Ferguson signed an executive order at the press conference that created an H.R. 1 response committee. The order directs state agencies to coordinate outreach, monitor coverage losses and help recipients respond to the new eligibility procedures, reinforcing the administration’s primary stated objective: preserving coverage for as many current recipients as possible. While pursuing those legitimate implementation responsibilities, I’m hopeful the outreach will include pointing Apple Health clients to employment resources, urging work as a way to exit poverty and improve one’s living situation.
The work requirement is expected to reduce federal Medicaid spending. Washington, meanwhile, stands to receive fewer federal matching dollars on which it has relied for years. That financial stake may explain the governor’s resistance more than moral outrage.
The federal government generally pays 90 percent of benefit costs for adults covered through Medicaid expansion, while the state pays 10 percent — equivalent to nine federal dollars for each state dollar. Lower enrollment will reduce federal Medicaid payments flowing into Washington. While it will also reduce the state’s corresponding share of benefit expenses, opponents of work requirements worry that the savings will be dwarfed by possible consequences such as increased uncompensated care at hospitals when people become uninsured. The state should be ready to direct what it previously spent on a Medicaid expansion client toward hospitals and other providers left with unpaid bills.
The federal work requirement will connect public assistance with employment or other community engagement and could promote greater independence, reduce poverty and decrease federal Medicaid spending. Our state leaders should be cheering that along and helping get more Washingtonians to work.
Instead, leadership here is criticizing the requirement and explaining how the state intends to verify compliance without client action when possible, identify exemptions, help clients retain eligibility despite the work requirement and measure coverage losses. Agency materials provide considerably less information about employment referrals, job placement or training opportunities.
The missing emphasis matters because the possible benefits of work extend far beyond taxpayer savings. Work can provide a livelihood, confidence, purpose, achievement, positive relationships, community inclusion and structured routines. Employment can also increase household income and create opportunities to move beyond dependence on public assistance.
Those benefits should not be omitted from the Medicaid debate: They’re the most important part of a work requirement.
Washington state is building an extensive system to determine who meets the new requirement and who does not. The larger test is whether the state will be as eager to help people trying to find work. The good that can come from H.R. 1’s work requirements will be measured in jobs, earnings, skills and greater independence — not merely in federal tax savings. Focusing on navigating the requirement instead of embracing it is a missed opportunity.
