Among the many provisions of the One Big Beautiful Bill Act are new rules around Medicaid.
In states that expanded the program, like Arizona, enrollees will have new work requirements; states will also have to check eligibility for the coverage every six months, rather than annually, like they do now.
And a new analysis from the Urban Institute finds between 27 and 55% of Medicaid beneficiaries in Arizona could lose their coverage in 2028 — that computes to between 123,000 and 246,000 Arizonans.
Matthew Buettgens, a senior fellow at the Urban Institute joined The Show
Full conversation
MARK BRODIE: And Matthew, what do you think are some of the biggest takeaways from the data you found about the impact of the One Big Beautiful Bill Act on state Medicaid enrollment?
MATTHEW BUETTGENS: Yes, many people have noted that this will decrease enrollment significantly. But not only did we quantify that, but the major thing that we added was that we looked at different decisions that states have when implementing this and found that it makes a huge difference. I mean, depending on the decision states make, the number of people losing coverage could be cut in like about half.
MARK BRODIE: Yeah, well, let's talk about that. You break them into what you're calling high mitigation scenario, medium mitigation scenario, and low mitigation scenario. What are you referring to there?
MATTHEW BUETTGENS: So in general it's state efforts to mitigate coverage loss is how that is framed. So, for example, a lot of this is dependent on quality data matches in real time to verify that people are either compliant with the work requirements or fall into one of the exemptions that can be verified. Now, states can make different efforts for those data matches. The data matches themselves will require some — a lot of things that currently are not being done.
So this will be new. And 2027 may sound like a while in the future, but that's not a lot of time for states to develop completely new administrative systems. So the systems may not initially work as intended. So it's the intensity that states use automatic data matches and their effectiveness. And some critical populations, it's difficult to get information for. Such as those who are self-employed. Like a lot of quarterly wage data, they don't show up there.
So you've got to look at other sources rather than like the sources that states currently use if you want to find them. And there's no easy answer on that.
MARK BRODIE: Well, it sounds like what you're saying is that even in states where they maybe want to take these sort of high mitigation scenarios and try to prevent people who should stay on Medicaid from being dropped, those efforts might not work, they might be unsuccessful and people might get dropped anyway.
MATTHEW BUETTGENS: Yes. ... So even in our high mitigation scenario, we're projecting a 25% drop in the Medicaid expansion population due to the OBBBA provisions. So there will be coverage losses. You can minimize them, but not—but only to a certain point.
MARK BRODIE: Are there lessons that you think we can learn about what this might look like based on how it's gone with states implementing provisions on SNAP on the food assistance program?
MATTHEW BUETTGENS: We're looking at that. There are important differences, and that's very recent. So more relevant are like the experiences of some states that have implemented work requirements in the past, such as Arkansas, New Hampshire, Michigan.
MARK BRODIE: For Medicaid specifically?
MATTHEW BUETTGENS: Yes, on Medicaid specifically. New Hampshire and Michigan never fully completed the implementation process, they were running it and before they actually started disenrolling people they discontinued those programs. So we do have the experience of those states.
And the one thing that comes out really clear in that is if people have to manually verify whether they comply with it or are exempt, then a large share — a majority in all of those cases — would end up getting disenrolled without us really knowing if they were exempt or compliant.
So whenever you introduce an administrative barrier like that, if you can't automatically verify it, there will be disenrollment. Um, and what we've what our work and work of many others has shown that a majority of Medicaid expansion enrollees are already working. And of those that aren't, a majority of them, you know, have certain health conditions or caregiving responsibilities or some other factor like that that is an exemption under the law.
MARK BRODIE: Let's talk for a minute about what you found with Arizona and going from the high mitigation scenario to the low mitigation. You found that basically Arizona at a minimum would lose 27% of enrollees in—in Medicaid here would lose their coverage. The medium mitigation scenario found 44% would lose coverage, and in the low mitigation scenario 55%, 246,000 Arizonans would lose their coverage. Obviously, that's not great for those individuals, but let's say that that one of those actually comes true, like what does that mean for the healthcare system here?
MATTHEW BUETTGENS: Yes. We'll start for the beneficiaries themselves. And the literature is clear that Medicaid expansion coverage without that, people are going to forego necessary healthcare. There were studies that Medicaid expansion reduced mortality and had a number of other health benefits.
Also, it's been established that Medicaid expansion has increased the financial security of enrollees. And in fact has decreased barriers to employment. So there's a number of health and economic benefits to the people getting Medicaid coverage that will be foregone if they lose that coverage.
Now, looking more broadly at the health system, there will be more uninsured people that healthcare providers will see and treat. So it will be an issue for healthcare providers and their revenue as well.
MARK BRODIE: Is this sort of a foregone conclusion at this point?
MATTHEW BUETTGENS: Yes, that is correct. The Congressional Budget Office and others have also done broad national projections of the number of people who'd be affected, and they're within our range. So definitely it will do that, and those provisions were designed to do that. And OBBBA, a lot of the federal spending cuts, the reason for that was to partially offset tax cuts elsewhere.
MARK BRODIE: Matthew Buettgens is a senior fellow at the Urban Institute.
EDITOR’S NOTE: This story has been updated to correct the spelling of Buettgens’
name.
