A May 1 virtual panel of Medicaid policy experts convened by the University of Pennsylvania’s Leonard Davis Institute of Health Economics (LDI) underscored a central tension shaping the program’s future—federal projections that millions could lose coverage under sweeping H.R. 1 changes versus a competing view that those estimates are exaggerated and that Medicaid should pivot toward promoting work and “independence.”

In opening the program, moderator and LDI Executive Director Rachel M. Werner, MD, PhD, cited Congressional Budget Office projections that $1 trillion in Medicaid funding cuts would result in 7 million people losing Medicaid coverage.

“While most of these changes to Medicaid have not yet gone into effect, the clock is ticking, and Medicaid officials across the country are scrambling to prepare for them,” Werner said. “They’re updating policy guidance, modifying complex IT systems, and communicating upcoming changes to both staff and beneficiaries and they’re making these consequential decisions without a lot of federal guidance, leading to concern that unclear rules, administrative complexity, and system challenges may lead to coverage disruptions, even for those who remain eligible under the new rules.”

Panelist Bruce D. Greenstein, Secretary of the Louisiana Department of Health, had a different view.

“Many Inconsistencies”

“In your description of the overall session today,” he said to Werner, “I find many inconsistencies with the way that we think about what we’re doing. You talk about these ‘dramatic cuts’ or ‘not enough guidance.’ I don’t feel like that’s the case at all. We’ve seen very limited changes. Nothing has changed thus far. They’re not real cuts. There is a reduction in the increases over time and more responsibility going back to states. As a state leader, we typically complain all the time about overarching Centers for Medicare and Medicaid Services (CMS) rules on states. In this case, we get to do what the law says, and I find it refreshing.”

Panelist Patricia Boozang, MPH, Senior Managing Director of Manatt Health, the consulting division of the national law firm Manatt, Phelps & Phillips, disagreed.

“There are many states and many policymakers that would disagree with your characterization of these not really being significant changes and that ‘this is right-sizing the program, getting it back to its original purpose, and there aren’t real cuts.’ I have heard these narratives before,” Boozang said to Greenstein. “But to restate, over 10 years the CBO projects cuts in federal funding to both Medicaid and the Affordable Care Act subsidies that will push 7 million people from Medicaid and close to 3 million from the ACA marketplaces. I think that’s important context—that the cuts and coverage losses are real.”

Work Requirements

Shifting to the bill’s work requirement, Werner asked panelist Benjamin Sommers, MD, PhD, to discuss the likely impact based on the latest research. Sommers is a Professor of Health Care Economics at the Harvard T.H. Chan School of Public Health.

He said Medicaid work requirements have been tested only in limited settings, with Arkansas providing the clearest real-world evidence after implementing them in 2018 under an 1115 waiver for adults ages 30 to 49. In the less than a year before courts halted the program, about 18,000 people lost Medicaid coverage. Follow-up research comparing Arkansas with nearby states found many of those individuals did not transition to jobs or employer-sponsored insurance as policymakers intended. Instead, there was a measurable increase in the number of people left uninsured, with no corresponding rise in employment.

Sommers said the core reason appears to be that the policy targeted a very small group: even before the work requirement took effect, more than 95% of eligible enrollees were already working or met exemption criteria, including health limitations, caregiving, school, or community service. As a result, the policy imposed verification burdens on a large population already compliant with its goals while affecting only a small fraction who were not working. The coverage losses, researchers found, were driven less by changes in work behavior than by administrative hurdles—“red tape”—including reporting requirements and confusion about the rules. About one-third of affected enrollees said they had never heard about the new requirement despite state outreach efforts.

Multi-Channel Outreach

Pointing to Louisiana’s work requirement plans, Greenstein said his state has begun an aggressive, multi-channel outreach campaign months ahead of formal enforcement, starting notifications in May for beneficiaries whose eligibility will be reviewed in early 2027. The state is sending layered communications—including letters, follow-up postcards, text messages, and emails—and timing them to give recipients a six-month window to demonstrate compliance.

Beyond direct notices, Louisiana is relying heavily on partnerships with health systems, clinics, health plans, and community providers to act as on-the-ground messengers. The state is also expanding call centers and support channels to handle increased demand and emphasizes “concierge-level” assistance for those subject to work requirements. Greenstein said outreach extends into community-based settings to reach people who may not respond to official notices, with the goal of ensuring that no eligible person loses coverage or encounters confusion or administrative barriers.

“From Dependence to Independence”

Greenstein framed “independence” as central to Medicaid work requirements’ success, describing the policy as a way to help people move “from dependence to independence” by transitioning out of Medicaid and into jobs with private insurance. He emphasized that the aim is not to remove people from coverage through administrative hurdles, but to connect them to employment opportunities and reduce long-term reliance on public assistance. In his view, independence means gaining stable work, employer-sponsored coverage, and economic self-sufficiency, with the state actively supporting that transition.

As the session approached its end, Werner asked the three panelists: “If you are advising a governor about what to focus on in their Medicaid program right now as these changes get implemented, what do you think is the most important thing to keep top of mind?”

• Boozang: “Focus on public communication—what you’re doing, why you’re doing it, and when you’re doing it. Be transparent about policy decisions. My other point is innovation. States have to be willing to innovate within their Medicaid programs to keep them sustainable and stable in a time of unprecedented fiscal pressures.”
• Greenstein: “Focus on action, not excuses. In the early days, we were hung up on defining medical frailty and were convinced we couldn’t do anything until CMS gave us guidance. Once our minds opened up and we knew we would get course correction if we were going in the wrong direction, we just put the pedal to the metal. My phone is always open for those who want coaching or guidance, and we’re happy to share what we’re doing with any other state or organization.”
• Sommers: “Three things: automation. Work requirement exemptions on paper don’t mean anything if the state can’t do them automatically. Medical frailty—use a longer lookback period, like three years or more. Third, generate better data, be more transparent, and report what’s actually happening. The more granularity we have in reporting, the better we’ll be able to get the policy right.”

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