When U.S. Rep. David Valadao defended voting for a bill aimed at reducing Medicare spending by billions, the Republican noted his role in securing a key provision that will require some adult beneficiaries to work — a mandate he called “not an unreasonable ask.”
But the voters in his California Central Valley district, home to one of the most competitive House races in the nation, might get a pass from the Medicaid work rules in the One Big Beautiful Bill Act, which President Donald Trump signed into law last summer.
Starting in January, the law requires many nondisabled adults enrolled in Medicaid in 43 states and Washington, D.C., to work, volunteer, or go to school for at least 80 hours a month. But those who live in counties where a high number of people are out of work could get relief — one of several carve-outs in the law.
“Based on current numbers, every county in CA-22 would qualify for this exemption,” Valadao’s website says, referring to his district. “This waiver is important because it takes real-life situations into account, and if someone is trying to work but opportunities are limited, they won’t be required to.”
The congressman, who has said enrollees in Medicaid — the federal-state program covering the poor and disabled — should “put in a fair day’s work” if they can, declined an interview request. Valadao campaign spokesperson Paige Ash also declined to comment.
Valadao is among at least 21 Republican lawmakers running for reelection who voted for the 2025 GOP bill and represent counties that could qualify for a hardship exception, according to a KFF Health News analysis.
Roughly 6 in 10 residents in Valadao’s district are enrolled in Medi-Cal, the state’s Medicaid program. Researchers have estimated 60,000 more residents of his district could be without coverage by 2034 as a result of the One Big Beautiful Bill and the expiration last year of enhanced premium tax credits for Affordable Care Act insurance plans.
“It feels akin to an arsonist trying to take credit for helping put out a fire that they themselves ignited when all of this was avoidable pain from the outset,” said Miranda Yaver, an assistant professor of health policy and management at the University of Pittsburgh.
Valadao faces Democrat Randy Villegas in a district that was redrawn last year to lean more blue, and the two sides had each booked more than $16 million in advertising through Election Day, according to data compiled by AdImpact. Villegas and other Democratic challengers nationwide have made Republicans’ Medicaid vote a centerpiece of their campaigns, saying most enrollees already work, are disabled, or are caregiving.
The law allows states to apply for a short-term hardship exception for enrollees who live in counties where unemployment is at least 8%, or at least 1.5 times the national rate, whichever is lower. But it’s unclear how the Trump administration intends to implement that relief.
Some states have yet to submit their applications. Five Democratic-led states have asked the federal government to delay the work requirements, citing insufficient time to comply before the end of the year.
The press office for the federal Centers for Medicare & Medicaid Services, which is implementing the new law, told KFF Health News in an unsigned email that states may submit unemployment data from a “reliable” source, including figures from their own labor departments. But the agency hasn’t said exactly what time frame of unemployment data states should provide.
Unemployment data can be reported in a variety of ways. It can be from the most recent month, or a 3-, 6-, or 12-month average. That data will determine how many counties — and how many people — might qualify.
Using July 2026 unemployment rates, which are not adjusted for seasonal swings, 95 U.S. counties would qualify for the exception, according to an analysis by KFF, a health information nonprofit that includes KFF Health News. Using the 12-month average, the number of qualifying counties jumps to 120.
“Which data is used matters,” said Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured. “I think there’s a lot still unknown.”
Sixty-four counties have high unemployment rates that will most likely qualify them no matter what data is used. The vast majority of the counties have a Republican representative. CMS declined to say how long exceptions would last or which states have applied. Indiana, Iowa, and Missouri do not plan to seek the hardship exception, according to KFF’s Medicaid work requirements tracker.
Some states are waiting for answers. California is among those that have asked to push back the start date. In September, the state asked CMS for permission to use state unemployment data that it says is timelier than federal data. State officials are waiting for a response, as well as for details about how long exemptions could be granted, said Griselda Melgoza, a spokesperson for the California Department of Health Care Services.
While blue states like California are seeking exceptions to help minimize the fallout of the new Medicaid rules, Yaver said any exceptions to the work rules could serve Republicans politically in the future.
“I think that exemptions and strategic burden reduction will ultimately undercut the accountability,” she said. “Because voters will just not really see the full reach of the law.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
What’s scarier than ghosts and goblins? How about measles, unaffordable dental care, and an insurance claim denied by artificial intelligence?
Nearly 80 healthcare-themed haikus crept into our inbox this Halloween season. Meet the winners of KFF Health News’ eighth annual Halloween haiku contest below.
Follow KFF Health News’ social media accounts (X, Instagram, and Facebook) for more of our favorites. Enjoy!
While Halloween may be coming to an end, KFF Health News reporting continues year-round. Send us your haikus at any time for possible inclusion in our Morning Briefing: https://kffhealthnews.org/contact-haiku/.
This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
When Ashley Porter began slurring her speech one October day four years ago, doctors suspected a stroke. A spinal tap, an MRI, dozens of blood draws, another MRI, and a night spent at the hospital were followed, finally, by an answer: Porter had multiple sclerosis.
Her shock turned to outrage, she said, when she received the roughly $180,000 hospital bill, even though insurance covered most of it.
Porter and her husband have insurance through two separate employer plans yet have spent at least $75,000 a year — roughly a quarter of their gross income — on medical expenses since her diagnosis.
“It is terrifying,” said Porter, who works in transportation sales in the San Francisco Bay Area. “I can’t imagine having this disease and not making the kind of income that we make.”
With health insurance premiums and hospital prices rising faster than inflation, more than 40% of adults nationally struggle to afford their care and, like most, want the government to address it.
The average premium for a California family with employer-sponsored coverage has hit nearly $28,400 a year, up 24% since 2022, much more than workers’ wages. Amid skyrocketing healthcare costs, the gubernatorial candidates’ proposals remain short on specifics about funding or implementation to address this top priority for voters in the nation’s largest healthcare market.
“People are hungry for pretty aggressive action on healthcare spending,” said Kristof Stremikis, director of market analysis and insight at the California Health Care Foundation, a nonprofit philanthropic organization specializing in healthcare research and education.
“Regardless of who our new governor is and who our new state policymakers are in the next year, they have a mandate,” he said.
Nearly two-thirds of Californians worry about receiving an unexpected medical bill, surpassing financial concerns such as the cost of rent or food, according to a 2025 CHCF-NORC survey. Six in 10 said they or a family member had skipped care because of cost.
Democrat Xavier Becerra, the former U.S. health secretary who has a commanding polling lead in the race for governor, has vowed to negotiate lower drug prices and go after anticompetitive practices as he did as attorney general in a landmark antitrust settlement with hospital giant Sutter Health.
He has also said that Congress should restore an estimated $900 billion in federal Medicaid cuts and reinstate enhanced Affordable Care Act tax credits that President Donald Trump and the Republican-controlled Congress allowed to expire, causing insurance premium payments to increase for millions of Americans. Both are national Democratic priorities outside a governor’s purview.
Former Fox News host Steve Hilton, Becerra’s Republican opponent, has said he’d build on existing state laws governing price transparency and prescription drug middlemen known as pharmacy benefit managers to lower costs. And he wants to partially replace Medi-Cal, the state Medicaid program, with personal healthcare accounts of up to $10,000 a year — a concept unlikely to gain traction in a statehouse controlled by Democrats.
Both candidates declined multiple interview requests to discuss their health policies.
Healthcare Costs and Consolidation
From 1970 to 2025, U.S. health expenditures ballooned from $75 billion to a projected $5.7 trillion, rising nearly 40% from 2020. By 2032, the Centers for Medicare & Medicaid Services predicts, health spending will account for more than a fifth of the U.S. economy.
Payments to hospitals, doctors, and clinics account for much of the inflation, along with rising prescription drug prices. Research shows that escalating mergers among physician practices, hospital groups, and insurers further stifled competition and raised prices.
In the 2018 lawsuit Becerra filed against Sutter Health, he accused the health system of using its market dominance to drive up hospital prices in Northern California, where procedures cost as much as 30% more than in other parts of the state.
The Sacramento-based not-for-profit system, which admitted no wrongdoing, paid an unprecedented $575 million fine and agreed to stop certain business practices, including imposing “all-or-nothing” terms on insurers that forced them to contract with the system’s entire network of clinics and hospitals.
“It was the biggest victory in antitrust and hospitals ever,” said Richard Scheffler, director of the Nicholas C. Petris Center on Health Care Markets and Consumer Welfare at the University of California-Berkeley. A report by the center, which conducts economic research on health policy topics, formed the basis of Becerra’s suit.
“But things change,” Scheffler said.
While the settlement likely discouraged similar practices by other hospital chains, he said, any relief has since been eclipsed by rapid consolidation in the healthcare industry.
At a press event in October, Becerra said he would work with the next state attorney general to “continue to look at the types of practices in healthcare that drive up costs.”
Hilton has said that he wants to increase competition by producing more generic drugs through California’s CalRx initiative, which aims to cut drug prices. He has said he wants to allow consumers to pick cheaper, pared-down insurance plans and force healthcare providers to make their prices more transparent.
Hospitals Under the Scope
Health economists say rising healthcare costs eat up money that employers might otherwise use for raises or new hires, depressing wages. That can be a double whammy for workers already struggling to meet basic needs and, consumer advocates warn, could increase medical debt, which 40% of California adults already report carrying.
Kia Frazier-Hill and her husband didn’t expect to be among them. She knew it would be expensive when he landed in the emergency room and was hospitalized at an out-of-network facility.
The astronomical prices gave her sticker shock: $17,507 for a night in the intensive care unit; $427.89 for a test for flu, covid, and RSV, or respiratory syncytial virus; $2.60 for a single tablet of generic, regular-strength Tylenol. Their bronze-tier plan from Covered California, the state’s ACA insurance marketplace, paid the vast majority, nearly $60,000, but the $7,500 balance has been in collections for months.
“We’re drowning,” Frazier-Hill said. “It just doesn’t make any sense what they’re charging.”
Researchers have found that hospital prices are even higher in uncompetitive markets.
California is trying to corral such runaway health costs through its Office of Health Care Affordability, which has directed most health systems, hospitals, insurers, and large healthcare provider groups to hold their spending growth to 3.5% this year.
Hospital and doctor groups, which have donated to Becerra’s campaign, say the cap is too low and will limit patient care, not improve efficiency.
“Hospitals have a mission to take care of people, save lives, and that costs money,” said Amber Ott, senior vice president of financial policy for the California Hospital Association, which is challenging the affordability board’s caps in court. “It’s hard to look at just one piece of the ecosystem and say that’s where the problem is.”
While hospitals are not the only drivers of high costs, they are the largest. According to the state, at least 40% of total health spending by commercial insurance plans went to hospitals in 2024, the latest data available.
Low-Hanging Fruit
As rising healthcare costs have driven up spending by public insurance programs and put pressure on state budgets, states have taken more of a lead in tackling affordability. But they are limited in what they can do. While California has led on prescription drug price transparency and negotiating more competitive marketplace plan rates, it lags other states in some respects, said Sabrina Corlette, a co-director of the Center on Health Insurance Reforms at Georgetown University.
“There’s a lot more they could do to rein in underlying drivers of healthcare costs,” she said of state policymakers.
Some states, for instance, have banned certain facility fees, which allow hospitals to charge higher prices than unaffiliated doctors’ offices even when services are rendered at outpatient clinics that they own. Corlette said such fees increase patient costs while incentivizing hospitals to gobble up more clinics and physician practices.
Oregon capped the payments its public employee health plans make to hospitals, reducing patients’ out-of-pocket spending on outpatient procedures by nearly 10%. Rhode Island limits hospital cost growth through an annual rate review of state-regulated health plans. California has done neither.
California healthcare advocates and researchers say there’s plenty of low-hanging policy fruit that could bring consumers more immediate relief. Insurers and providers could work to automate notoriously inefficient prior authorization procedures, while lawmakers could mandate shorter insurer response times to prior authorization requests, as New Jersey and Vermont have done.
The legislature could also broaden bans on anticompetitive contracting, much like Connecticut and Texas, or expand on Los Angeles County’s program to purchase and forgive residents’ medical debt.
Heath policy experts say even those relatively modest ideas would be a heavy lift in Sacramento, where the industry spends tens of millions of dollars annually to influence lawmakers and state agencies.
“It’s a big, complicated system, and the money is so gigantic,” said Glenn Melnick, a healthcare economist at the University of Southern California. “At some point, the legislature has to hold the line and say, ‘Look, it is the golden goose, but we’re going to have to feed it a little bit less.’”
This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
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