Episode Details

In this episode of The 80 Million Podcast, Manatt Health Senior Managing Director and 80 Million Editor Patti Boozang speaks with Professor of the Practice at Princeton University’s School of Public and International Affairs and State Health and Value Strategies Director Heather Howard and Manatt Health Partner Allison Orris about what H.R. 1 implementation looks like on the ground as states build against a moving target and work to minimize avoidable coverage losses.

Authors: Heather Howard and Allison Orris

Editors: Patti Boozang and Amanda Eisenberg

tl;dr

* Last year’s reconciliation law made unprecedented cuts to Medicaid that will shape the program and our health care ecosystem for years to come. States are building against a moving target even as their implementation efforts are well underway — such as stripping Medicaid coverage from certain lawfully present immigrants as required by H.R. 1 and operationalizing work reporting requirements, more frequent eligibility redeterminations and limits on retroactive eligibility that take effect in January 2027.

* States are adapting their systems and policies to major, late-breaking policy changes in the administration’s work reporting requirements rule. At the same time, they are making critical policy and budget decisions as federal rules governing Section 1115 demonstrations, provider taxes, and state-directed payments continue to evolve ahead of key implementation deadlines.

* Coverage losses are a major part of the story. Rising uncompensated care and financing changes made by H.R. 1 will also put pressure on Medicaid agencies, providers and state budgets in ways that will be broadly felt beyond people enrolled in Medicaid.

* This next year will generate critical evidence. Hard data could take longer but providers will soon see evidence of rising coverage losses and uncompensated care. Other early indicators — most especially enrollees’ experiences navigating new systems — can help policymakers understand how implementation is working in practice.

The 80 Million Impact

H.R. 1’s Medicaid changes are arriving in waves, but states are already feeling the cumulative pressure as they prepare to implement various provisions of the law and consider how they will respond to the fallout from rising uninsurance, uncompensated care and budgetary constraints.

The law cut nearly $1 trillion in federal Medicaid funding over the next decade, making major structural changes to significant parts of how the program operates. Although some of its biggest provisions do not take effect until 2027 or later — and federal guidance on some provisions is still pending — states have been working to implement these changes at record speed because of tight timelines and high stakes for their enrollees. Getting ready to implement the new Med