Key Tensions Shape the H.R. 1 Debate
A fierce debate surrounds proposed H.R. 1 Medicaid changes. On one side, federal projections warn that millions could lose health coverage. On the other, some policymakers argue those estimates are exaggerated. They believe Medicaid reform should promote work and self-sufficiency.
On May 1, 2026, the University of Pennsylvania’s Leonard Davis Institute of Health Economics (LDI) hosted a virtual panel. Medicaid policy experts from across the country joined the session. Together, they examined the real-world impact of the proposed changes.
LDI Executive Director Rachel M. Werner, MD, PhD, opened the discussion. She cited Congressional Budget Office (CBO) projections showing $1 trillion in Medicaid funding cuts. According to those projections, 7 million people could lose Medicaid coverage as a result.
Werner also highlighted a critical implementation problem. “Medicaid officials across the country are scrambling to prepare,” she said. They update policy guidance, modify complex IT systems, and notify staff and beneficiaries. Yet they do this without clear federal guidance. This creates a serious risk of coverage disruptions—even for people who remain eligible under the new rules.
Experts Clash Over “Real Cuts”
Louisiana Secretary Defends the Changes
Bruce D. Greenstein, Secretary of the Louisiana Department of Health, pushed back on Werner’s framing. He argued that calling the changes “dramatic cuts” misrepresents what is happening. “Nothing has changed thus far,” Greenstein said. He described the modifications as a reduction in the rate of spending increases, not actual cuts. In his view, the changes return responsibility to states. He called this shift refreshing.
Manatt Health Expert Challenges That View
Patricia Boozang, MPH, Senior Managing Director of Manatt Health, disagreed directly. She challenged the idea that the program simply returns to its original purpose. Over ten years, she explained, the CBO projects cuts to both Medicaid and Affordable Care Act (ACA) subsidies. The result: 7 million people pushed out of Medicaid and nearly 3 million removed from ACA marketplaces. “The cuts and coverage losses are real,” Boozang said firmly.
What Research Shows on Work Requirements
Arkansas Provides the Clearest Evidence
Benjamin Sommers, MD, PhD, Professor of Health Care Economics at Harvard T.H. Chan School of Public Health, analyzed the research. He explained that Medicaid work requirements have limited real-world testing. Arkansas offers the clearest example. The state implemented work requirements in 2018 under an 1115 waiver for adults ages 30 to 49.
Courts halted the program within a year. Nevertheless, the effects were significant. About 18,000 people lost Medicaid coverage during that short period.
Work Requirements Did Not Increase Employment
Follow-up research compared Arkansas to neighboring states. Notably, the results were discouraging. Many people who lost coverage did not find jobs. Likewise, they did not transition to employer-sponsored insurance. Instead, researchers recorded a measurable rise in the uninsured population—with no corresponding increase in employment.
Sommers explained why. More than 95% of eligible enrollees already worked or met exemption criteria before the requirement took effect. Therefore, the policy imposed verification burdens on a largely compliant population. The coverage losses stemmed primarily from administrative hurdles—reporting requirements, confusing rules, and poor outreach. Approximately one-third of affected enrollees said they had never heard of the new requirement.
Louisiana’s Outreach Strategy
A Multi-Channel Communication Campaign
Greenstein described Louisiana’s proactive approach. The state launched an aggressive, multi-channel outreach campaign months before formal enforcement. Notifications began in May 2026 for beneficiaries whose eligibility review starts in early 2027.
Louisiana sends layered communications: letters, follow-up postcards, text messages, and emails. Furthermore, the state gives recipients a six-month window to demonstrate compliance. This approach aims to minimize confusion and protect eligible enrollees.
Community Partnerships Drive the Effort
Beyond direct mail, Louisiana partners with health systems, clinics, health plans, and community providers. These organizations serve as on-the-ground messengers. Additionally, the state expands call centers and support channels to manage increased demand. Greenstein emphasized that the goal is “concierge-level” assistance for those subject to work requirements. The state also conducts outreach in community settings to reach people who may not respond to official notices.
The Independence Argument
Greenstein framed independence as the policy’s central purpose. He described work requirements as a pathway—helping people move from dependence to employment and private insurance. His argument is that the state does not aim to remove people from coverage through bureaucratic barriers. Rather, it aims to connect them to jobs and long-term economic stability. In his view, true independence means stable employment, employer-sponsored coverage, and self-sufficiency.
Critics, however, point out that this framing conflicts with the research. Evidence from Arkansas suggests that administrative barriers—not behavior change—drive coverage losses.
Expert Advice for State Governors
As the panel closed, Werner asked each expert one final question: What should governors prioritize as H.R. 1 changes roll out?
Boozang: Communicate and Innovate
Boozang urged states to prioritize public communication. Governors should explain clearly what is changing, why it is changing, and when. Transparency matters. She also called for innovation. States must find new ways to keep their Medicaid programs sustainable under unprecedented fiscal pressure.
Greenstein: Act Without Waiting
Greenstein advised governors to focus on action, not excuses. Louisiana initially stalled while awaiting federal guidance on medical frailty definitions. Once the state moved forward independently, progress accelerated. He offered his state’s experience as a model and welcomed collaboration from other states.
Sommers: Automate, Protect the Frail, and Report
Sommers recommended three priorities. First, automate work requirement exemptions. Paper exemptions mean little if the system cannot process them automatically. Second, use a longer lookback period—at least three years—when assessing medical frailty. Third, generate better data. Transparent, granular reporting helps policymakers identify problems and correct course quickly.
