The speed and scale of changes to the Medicaid program required by the so-called “One Big Beautiful Bill Act” (OBBBA) will strain Medicaid administrative functions, creating failures that will harm applicants and enrollees, including those with disabilities. OBBBA significantly increases administrative burdens on many enrollees and eligibility staff through more frequent renewals, work requirements, and other eligibility checks. OBBBA gives states an extremely compressed and insufficient timeline to implement drastic changes, while simultaneously cutting Medicaid funding to states in the amount of $990 billion over 10 years. Past prior major changes in Medicaid have led to implementation issues that harm applicants and enrollees. To mitigate similar harms while implementing OBBBA, states should take proactive action to set up systems, processes, and resources to protect people from these harms and quickly remediate the harms that do occur. There should be a “landing pad” for when the inevitable system failures occur in the safety net programs from the pressures of OBBBA’s changes.
Eligibility Changes Historically Lead to Dysfunction & Harm
History shows that in times of substantial Medicaid eligibility change or administrative burden, there will be significant expected and unexpected problems. For example, the Affordable Care Act contained numerous eligibility changes comparable in scope to OBBBA. Unlike with OBBBA, states had years to prepare for these changes. Nevertheless, states were still drowning in administrative and eligibility system issues, and struggled to implement new policies and system changes.
Moreover, restarting eligibility redeterminations following the height of the COVID-19 pandemic (“the unwinding”) demonstrated that many states struggle with resolving problems when resources are stretched. By June 2024, after most of the unwinding was complete, more than 17 million people had been disenrolled from Medicaid because of procedural or paperwork issues. Nearly one-third of those individuals regained coverage after a short period, indicating they likely were eligible for Medicaid but incorrectly terminated. Many people with disabilities complained of improper coverage losses, including loss of critical services. Although some states were able to mitigate coverage loss through interim processes, many people were harmed before problems were identified and acted on.
OBBBA’s changes are likely to create problems not only for the populations specifically subjected to work requirements, but will likely cause confusion and delays for all eligibility processes. This is especially true in states that use the same workers for Medicaid and SNAP processing, as OBBBA changed requirements in SNAP as well. For example, during the unwinding, call centers had persistent, significant wait times affecting SNAP and Medicaid. Many applicants and enrollees could not get their questions answered and thus were unable to respond to the state’s requests for eligibility information, often leading to terminations. States made efforts to address these issues or put in place help for specific populations, but applicants and enrollees were harmed while states attempted to remediate these issues.
States Should Use Proactive Protections Rather than Reactive Patches
Advocates can learn from these lessons and take proactive steps to push states to put in place needed resources and processes before the problems begin. This includes ensuring that states provide reliable, specific sources of information and often individual advocacy support to resolve issues that arise from massive programmatic changes. Given the high likelihood that OBBBA will cause individuals to fall through the Medicaid safety net, advocates should focus their energy at this moment on pushing their state to build a “landing pad” of resources, networks, and other alternative services for enrollees. A “landing pad” is especially important for people with disabilities, who are at high risk of severe negative health outcomes or death if they go without needed services, even for a short period of time.
Considerations for a “Landing Pad” to Cushion Harm from Administrative Dysfunction
In working to establish a “landing pad” in your state, advocates may want to consider the following questions:
- What was needed during Medicaid Unwinding to prevent worst-case scenarios? Were there helpful processes that may be replicated for OBBBA implementation? Were there clear gaps that were not in place that should be addressed?
- What outreach and education efforts have been most successful for the Medicaid-eligible population? The OBBBA changes to Medicaid are complex for those they affect directly, and confusing for others. What role will the state have and who else are appropriate messengers?
- Is there a state-based coalition of legal services organizations, disability advocacy groups, and other relevant organizations in place to share problems, ideas, and knowledge on how to address worst-case scenarios? If not, would one be useful?
- What mechanisms does the State Medicaid Agency have to facilitate problem-solving for Medicaid enrollees? Are these mechanisms sufficient?
- Has the State Medicaid Agency identified resources for specific populations, such as older adults, people with disabilities, people receiving home and community-based services (HCBS), and people with ongoing critical care needs? For example, are there any specific helplines or resource centers that are designated for specific populations? For OBBBA, specially trained call center staff to handle non-expansion eligibility issues or resource centers to help specific populations understand if they are eligible for certain exclusions may be needed.
- Do advocates have a direct line to an individual or group within the Medicaid Agency that has the authority to address individual problems?
- Specifically for people with disabilities:
- Does the state have a system in place to provide reasonable accommodations for people with disabilities? In addition to accommodations like auxiliary aids for people with communication issues, the state should have a system of accommodations in place for people with developmental, cognitive, or other disabilities to ensure effective communication and understanding of program requirements.
- Do all frontline staff, including call center staff, understand disability access and how to process a request for help based on disability? Are there specific staff who people may be referred to?
- If a person who receives HCBS or other essential care loses coverage, and thus is at risk of serious injury or death, what mechanisms are in place to immediately resolve the issue and provide alternative means of support until resolved? Does this process work in both fee for service and managed care?
- What type of funding is in place to support a “landing pad”?
- Advocates should use the current or upcoming legislative session to press for needed funding for effective resources that could mitigate harms caused by the changes in OBBBA. Resources to get through implementation in 2026 and 2027 will likely need to be appropriated this year in many states.
- Examples of funding requests include boosting existing customer services operations and call centers, creating a targeted ombudsman-type program specific to helping people with work requirement issues or eligibility writ large, and designating state funding for emergency direct services if an enrollee experiences an unanticipated gap in Medicaid coverage.
- When advocating for these programs, advocates should emphasize that funding these types of initiatives will ultimately save the state money by preventing Medicaid churn (disenrollment followed by reenrollment), decreasing the strain on eligibility workers, and lessening the need to rely on emergency health care services.
Given the draconian nature of OBBBA, it is unlikely that all harms to Medicaid applicants and enrollees can be avoided. However, by working now to establish a “landing pad” for individuals who lose coverage, advocates can encourage states to prevent the worst-case scenarios. You can learn more about other potential OBBBA advocacy efforts you can take in your state here.
