Effects of HR1 Implementation on Medicaid Enrollment and Mitigation Strategies

Session Submission Type: Panel

Abstract

The One Big Beautiful Bill (H.R. 1), passed in July 2025, includes extensive changes to the Medicaid program, including work requirements that must be verified at least every six months and limited eligibility for qualified noncitizens. The Congressional Budget Office estimates that H.R. 1 will reduce Medicaid spending by more than $900 billion over 10 years, mostly through coverage loss (Hinton et al. 2025). In this panel, we will hear from a diverse array of policy experts on ongoing efforts to 1) quantify anticipated coverage losses and 2) mitigate coverage losses via state and local policy implementation. 

First, we will hear from the Better Government Lab about their partnership with the Alameda County Health Department to forecast coverage losses among immigrants and adults subject to work requirements. Dr. Katherine Richard will first outline how stages of H.R. 1 implementation are likely to impact different groups, before presenting details of a microsimulation model used to forecast coverage losses. Using aggregate-administrative data on county Medicaid enrollment and utilization, authors will compare realized and forecasted coverage losses to learn about how H.R. 1 is impacting low income and immigrant communities in real time. 

Next, we will consider how state and local implementation choices will shape Medicaid coverage losses resulting from H.R. 1. Michael Karpman (Urban Institute) will estimate state-by-state changes in average monthly Medicaid expansion enrollment in 2028, using Urban Institute’s Health Insurance Policy Simulation Model (HIPSM) and public survey data. The authors compare enrollment changes assuming varying levels of state mitigation efforts that depend on the extent to which eligibility or exemptions from work requirements can be automatically determined. They find that Medicaid enrollment would decline by 27% and 55% in 2028 under high and low mitigation scenarios respectively, which varies greatly by the extent to which states use claims data to exempt medically frail enrollees. 

Third, Dr. Adrianna McInytre will present results from a randomized control trial in which Medicaid enrollees who could not be renewed on an automatic (ex parte) basis were assigned to receive reminders or application assistance. They find that while reminders slightly increase the likelihood of submitting a redetermination packet, packet returns increased by approximately 6% and successful renewals increased by 8-11% among those who received application assistance. Simple reminders were more effective for child and young adult enrollees, while application assistance was more effective for older (65+) and non-Hispanic Black enrollees. Their findings suggest that higher-touch interventions are better at preventing avoidable Medicaid coverage loss than low-touch (information only) interventions.
 
Finally, Dr. Michelle Miller-Adams will discuss the Upjohn Institute's work with cross-sector coalitions in Michigan. She will compare ongoing efforts of the Kent County Medicaid Task Force and the Medicaid Access Coalition of Kalamazoo, which bring together local hospitals, health care providers, social service agencies and non profit organizations. Through qualitative interviews, participant-observation, and cost-benefit analysis, this presentation will provide insight into the dynamics of local coalitions and how other communities might structure their efforts to protect health insurance access while complying with HR1.

Policy Area

• Health Policy

Chair

• Christine Piette Durrance, University of Wisconsin-Madison

Discussants

• Laura Dague, Texas A&M University

• Ari Ne'eman, Harvard University

Organizer

• Katherine Richard, University of Wisconsin-Madison

Individual Presentations

• Distributional Effects of HR1 Implementation on Medicaid Enrollment - Presenting Author: Katherine Richard, University of Wisconsin-Madison

• Projecting Coverage Impacts of State Implementation Choices Under Medicaid Work Requirements and 6-Month Eligibility Redeterminations - Presenting Author: Michael Karpman, Urban Institute

• Evaluation of Randomized Medicaid Redetermination Assistance - Presenting Author: Adrianna McIntyre, Harvard University

• Medicaid work reporting rules and local responses: Lessons from two Michigan communities - Presenting Author: Michelle Miller-Adams, W. E. Upjohn Institute for Employment Research