Ohio bucked the national trend in 2013, expanding Medicaid under a Republican governor and state legislature, but that expansion could now be in jeopardy. While the Democrats running for governor in 2018 have vowed to preserve the expansion, the GOP frontrunner wants a more aggressive federal waiver to block-grant Medicaid, impose work requirements and implement other restrictions, and his primary opponent has vowed to kill the expansion entirely.

Ohio’s May primary and November general election will determine the future of health care in a state whose death toll from opioid overdoses is second in the nation, and whose rural hospitals depend heavily on Medicaid for their survival.

Since Ohio Gov. John Kasich became one of very few Republican governors to embrace the expansion of Medicaid under Obamacare, the state has expanded coverage to roughly 700,000 previously uninsured people. Even though Kasich garnered a massive political backlash because of the move, he has since urged other GOP states to follow him and beaten back attempts from his own state party to chip away at the program. In 2017, he vetoed a bill passed by the Republican supermajority in the state legislature that would have frozen Medicaid enrollment and forced low-income enrollees to pay insurance premiums.

Any day now, however, Kasich will submit a request to the Department of Health and Human Services for permission to force those enrolled in the state’s Medicaid expansion to prove they’re working at least 80 hours per month. If the waiver is approved by the Trump administration, Ohioans unable to find work would have get placed with an organization in their county and work without pay to earn the value of their health care benefits.

At a recent campaign stop in Youngstown, the GOP frontrunner to replace Kasich, Attorney General Mike DeWine, told TPM he plans to go even further if elected governor.

“Our waiver might be even bigger,” he said. “We would want the ability to really redesign Medicaid, in particular regard to the people covered under the Medicaid expansion.”

But when TPM asked what exactly his Medicaid vision would entail, asking if he would, for example, follow other states in making beneficiaries pay premiums and subject them to lifetime limits, DeWine demurred.

“We have not come up with all the details,” he said. “But we know that we want to put a lot more emphasis on prevention.”

DeWine’s spokesperson, Ryan Stubenrauch, revealed more in an e-mail to the National Journal, saying the candidate “[plans] to utilize the increased flexibility of the Trump administration to seek waivers to pursue block granting of funds, a work requirement for able-bodied adults, and a redesigned medical services approach to Medicaid that emphasizes prevention and value based purchasing as a way to reduce costs.”

DeWine has focused much of his campaign on addressing the state’s opioid addiction epidemic, which claims thousands of lives each year. Though many lawmakers and medical professionals say the Medicaid work requirement could push thousands of people struggling with addiction out of treatment, DeWine insisted to TPM that they would be safely exempted.

“We’re making sure that we take of the people who are the most vulnerable and that certainly includes people who are in recovery,” he said. “All we’re saying with the work requirement is: if you’re an able-bodied adult and you do not have medical problems, you should be on the pathway to get out of dependency, and the way you do that is with a job. But for someone who is a recovering addict, the most important job they have is recovering, so they need to stay in that program, and Medicaid as I envision it would certainly accommodate that.”

But if Ohio’s waiver is approved, each county would be tasked with screening Medicaid enrollees to determine if they qualify for an exemption to the work requirement, and since there is no set legal definition of “recovering addict,” patient advocates worry that people will fall through the cracks. Additionally, because of the stigma associated with addiction, many may avoid seeking an exemption, and lose their Medicaid coverage.

DeWine’s primary opponent, Lt. Gov. Mary Taylor, is running to his right, particularly on health care. On Tuesday, she released an ad vowing to “end John Kasich’s Medicaid expansion.”

Though Taylor is trailing DeWine in recent polls, endorsements from national arch-conservatives like Sen. Ted Cruz (R-TX) have boosted her campaign, prompting DeWine to publicly criticize her as “a conservative who has not really done things.”

In contrast, both of the top Democratic candidates for governor say they will preserve the Medicaid expansion and explore ways to provide more health care options to Ohioans.

“I’m an adamant supporter of the Medicaid expansion,” frontrunner Richard Cordray told TPM at a campaign stop in Columbus. “I think it’s crucial to health care in the state and important for the economy.”

Cordray added that he considers Kasich’s push for work requirements, endorsed by both Taylor and DeWine, “really stupid.”

“It’s a health care program. It’s not a work program,” Cordray said. “First of all, most of those people are disabled or they’re already looking for work. So it’s really a symbolic thing they want to do — a political statement. It’s going to apply to a very small slice [of people], but it’s really going to hurt that slice. What’s it going to do? It’s going to push them out of the health care system, and eventually they’re going to need treatment and they’ll come to the emergency room and we’ll all pay the price for that.”

Ohio’s non-profit Center for Health Affairs estimates that 18,000 people could lose their health coverage due to the requirement, though advocacy groups say that number could be much higher if eligible people are deterred by the bureaucratic hoops they have to jump through to document their employment status or prove they’re exempt due to a disability.

Cordray’s main primary opponent, former Cleveland mayor and House member Dennis Kucinich, beyond a promise to preserve the state’s Medicaid expansion, has said he would enact “a comprehensive plan, to provide every Ohioan with access to affordable, low-cost, basic medical, mental health, dental, and prescription drug care.”

Should Cordray and DeWine prevail in the May 8 primary as expected, the race is currently a toss-up.