Opinion: 3 things new governors must do to lead on health

As former state health leaders, we know the challenges and opportunities facing the 21 new governors stepping into their roles on Jan. 1. Health is what lets people go to work, raise their kids, and enjoy the years they’ve earned. Health is also the largest line item in most state budgets and a primary driver of the affordability crisis for American families. To succeed in harnessing the power of state government to improve health and well-being and tackle affordability, new governors need to do three things: hire operators, see the trouble that’s already here, and set a focused agenda. Hire operators A governor’s three most consequential health appointments are the state’s health and human services secretary, Medicaid director, and public health officer. The attributes that matter most in these leaders include, foremost, a track record in getting things done in and with government. Look for leaders who have managed large government teams, legislative processes, and stakeholder associations. Expertise matters, especially in this moment. The Medicaid director should understand evolving federal financing rules, eligibility systems and operations, and the state’s Medicaid delivery system, which is often managed care. The public health officer should have run an outbreak response. Relationship and communication skills are paramount in managing a large government agency through change. The governor’s health leaders need to have the trust of legislators of both parties, hospitals, health centers and other health care providers, local leaders, consumer groups, and community partners. This team will be the state’s public face and primary communicators in a crisis. See the trouble that’s already here Issues that are already hitting states hard will become even more challenging in the coming year. Governors-elect should be briefed on them now. Medicaid eligibility requirements: In expansion states, work requirements and more frequent redeterminations of Medicaid eligibility are set to go live on Jan. 1, 2027. These new road rules require expansion adults ages 19 to 64 to document 80 hours a month of work, school, or service and to prove eligibility for Medicaid every six months. Experience shows that coverage losses will be high and come from paperwork, not because residents aren’t eligible for Medicaid anymore. These federal mandates will have major local impact. Governors should know: How well state systems verify eligibility data, especially new work exemptions, automatically from existing data. Who is most at risk of losing coverage over paperwork, and what the agency is we doing to reach them and prevent that outcome. Whether the state submitted a request to CMS to delay work requirements implementation. Measles: The U.S. has already recorded more cases of measles in 2026 than in any year since 1991, nearly all among unvaccinated people. An international review this week will assess whether the country has lost its elimination status. On day one, governors should know kindergarten vaccination rates by county, confirm outbreak plans and surge staffing, and have a crisis communication plan at the ready for when an outbreak hits. Medicaid program integrity: Medicaid program integrity is a concern for every state, and governors should expect CMS scrutiny to continue. The Centers for Medicare and Medicaid Services has required all 50 states to submit Medicaid provider revalidation plans and has withheld federal payments from at least one state. New executive health teams should assume a review is coming and give the state’s fraud and inspector general units the resources they need and make program integrity the state’s own priority. Set a focused agenda Aligning priorities across program and funding silos is a core job of the governor and their health team. With sustained leadership and clear focus, a state can unlock enormous untapped potential across Medicaid, public health, social services, insurance regulation, the state employee health plan, and rural health funds. This should include clarity of which levers states control and which require federal partnership (such as Medicaid or ACA waivers and financing changes). Governors should prioritize action in those areas that the state can drive. Governors should elevate key priorities to name in the first State of the State, fund in the first governor’s budget, and show results within two years. Strong candidates for priorities are: Coverage: Ten states still have not expanded Medicaid access. For these states, four of which have new governors coming in January, expansion should be a priority. It’s still the biggest lever for coverage, rural hospital sustainability, and funding. In any state, governors can create a public option to make premiums more affordable and give struggling small employers relief. Affordability: The first affordability priority for new governors — indeed, for all governors — should be relief that families feel soon. Options to consider include capping out-of-pocket costs for high-use medications, making primary care available before the deductible kicks in, and reining in pharmacy costs through pharmacy benefit manager reform and drug price transparency. States can also protect patients from surprise and excessive bills by limiting facility fees, strengthening hospital financial assistance standards, and adding medical debt protections. Lasting affordability also requires bringing down the overall cost of care — something that is a shared responsibility across hospitals, insurers, and drug manufacturers. Governors can set cost growth targets and compel public reporting. They can use combined state purchasing power to drive value-based payment and cut administrative waste. They can also pay for care models that improve access and chronic disease management, such as value-based primary care and technology-enabled models aligned with Medicare’s ACCESS model. Rural health: Every state received a Rural Health Transformation Program award, averaging about $200 million a year through 2030, and later funding depends on meeting the commitments in each state’s application. It’s critical to avoid the “peanut butter” approach — spreading the dollars over so many priorities that the money is thin for all. Set a few measurable goals, such as keeping obstetric and emergency services open, building regional referral networks, and building and maintaining primary care and behavioral health access. Plan for how to sustain the work after federal funding ends. States should approach artificial intelligence thoughtfully as they invest rural health and other state funds. Used well, AI holds promise to improve access, health, and the work of state government. Used poorly, it can drive up costs and deny care. To guide AI investment, governors should set clear, simple rules that protect consumers through disclosure, consent, and clinician review, aligned with other states. Use Medicaid managed care contracts and state purchasing to require disclosure of AI use and reporting of outcomes, steering vendors toward tools that improve access and affordability rather than AI automation billing wars. Start small with initiatives inside state government where AI can support your workforce including by piloting AI in chatbots, call centers, and eligibility processing, with human review of any decision that denies or ends coverage. A divided government in Washington likely means few federal solutions are coming soon. States have always been laboratories of innovation, and that power has never been more critical to harness than at this moment. Mandy Cohen, M.D., M.P.H., is former secretary of health and human services for North Carolina and former director of the Centers for Disease Control and Prevention. She is a national adviser at Manatt, a legal and consulting firm. Ellen Montz, Ph.D., is former chief deputy at the Virginia Department of Medical Assistance Services (Virginia Medicaid) and former deputy administrator and director at the Center for Consumer Information and Insurance Oversight at the Centers for Medicare and Medicaid Services. She is a managing director at Manatt.