Dissecting the Deepest Cuts: New Barriers to Medicaid Eligibility and Enrollment

The 2025 budget reconciliation law (H.R. 1) imposes major new restrictions that will make it significantly harder for eligible adults to enroll in the Affordable Care Act's (ACA's) Medicaid expansion coverage and, once enrolled, access care. Starting January 1, 2027, H.R. 1 will impose two major new enrollment hurdles on the expansion population: renewals every six months (rather than yearly) and mandatory work reporting compliance. These barriers are expected to lead to loss of coverage on top of the improper denials and disenrollments that states already produce through the ordinary eligibility process. Together, these could cost 4.9 to 10.1 million people their Medicaid access by 2028 - with the Centers for Medicare & Medicaid Services (CMS)'s more stringent implementing rules adding an additional 1.8 million people to that toll. Below is a detailed explanation of H.R. 1's new Medicaid eligibility requirements and their impact on consumers and providers, along with an examination of state implementation choices that either reduce paperwork and preserve coverage or add barriers and accelerate coverage loss. A companion explainer covers new mandatory cost sharing for expansion adults, which will sharply raise out-of-pocket costs for those who retain their coverage.