The One Big Beautiful Budget Act (OBBBA) — the sweeping federal budget reconciliation package advancing through Congress in 2025–2026 — contains Medicaid provisions that researchers and policy analysts at AJMC and the Center on Budget and Policy Priorities have identified as potentially the most significant restructuring of the program since the Affordable Care Act. For the roughly 80 million Americans currently enrolled in Medicaid, understanding which populations face the highest risk of losing coverage is the first step toward protecting access to care or identifying backup options.

Who Is Most at Risk Under the OBBBA?

1. Working Adults in Medicaid Expansion States

The OBBBA proposes mandatory work reporting requirements — sometimes called community engagement requirements — for non-elderly, non-pregnant adults who gained coverage through the ACA's Medicaid expansion. Under expansion, adults with household incomes at or below 138% of the Federal Poverty Level (FPL) became eligible in the 40 states (plus D.C.) that adopted expansion.

The proposed requirements would mandate that enrollees document a minimum number of hours per month in qualifying activities — employment, job training, education, or caregiving — or risk losing coverage. Research from prior state-level experiments with work requirements (Arkansas, 2018) found that the majority of people who lost coverage were already working but failed to navigate the paperwork, not because they were unemployed. Administrative burden, not actual non-compliance, is the primary driver of disenrollment under these structures.

What to do: If you are currently enrolled in Medicaid expansion and work requirements are implemented in your state, gather documentation now: pay stubs, employer contact information, school enrollment records, or caregiver documentation. Your state Medicaid agency will be the source of official notice.

2. Lawfully Present Immigrants

Current federal law already restricts most immigrants from Medicaid for five years after obtaining lawful status. Several states used their own funds or ACA flexibility to extend coverage to lawfully present immigrants beyond federal minimums. The OBBBA contains provisions that could restrict states' ability to use federal matching funds for these populations, effectively forcing states to either fund coverage entirely with state dollars or eliminate it.

Lawfully present immigrants — including green card holders, refugees, asylees, and DACA recipients in states that extended coverage — are among the most vulnerable to losing Medicaid access under these changes.

What to do: Federally Qualified Health Centers (FQHCs) provide care on a sliding-fee scale regardless of immigration status. Use the HRSA Health Center Finder at findahealthcenter.hrsa.gov to locate the nearest FQHC. Many pharmaceutical manufacturers also offer Patient Assistance Programs (PAPs) for uninsured or underinsured individuals — NeedyMeds.org and RxAssist.org are free directories.

3. People With Disabilities on Home and Community-Based Services (HCBS) Waivers

Medicaid HCBS waivers allow states to provide long-term services and supports — personal care, supported employment, residential services — to people with disabilities in community settings rather than institutions. The OBBBA's proposed per-capita cap or block grant funding structures would give states a fixed federal payment per enrollee rather than the current open-ended federal match.

When states face a fixed federal allotment, HCBS waiver programs — which are optional, not mandatory, under federal Medicaid law — are historically among the first services reduced or waitlisted. An estimated 700,000 people are already on HCBS waiver waiting lists nationally; funding caps could extend those waits significantly.

What to do: Contact your state's Medicaid agency and your state legislators directly. Disability rights organizations such as the National Disability Rights Network (ndrn.org) provide free legal advocacy and can help you understand your state-specific waiver status.

4. Low-Income Parents and Caretaker Relatives

Before ACA expansion, most states covered parents only up to 61% to 100% of FPL — and some states set thresholds as low as 17% to 25% of FPL. Expansion raised the floor to 138% of FPL for all adults. If the OBBBA reduces or eliminates the enhanced federal matching rate (currently 90%) that incentivizes states to maintain expansion, some states may roll back parent eligibility to pre-ACA levels.

Low-income parents who lose Medicaid may find their children remain eligible for the Children's Health Insurance Program (CHIP), which covers children in households up to 200% to 300% of FPL depending on the state. However, parents themselves could face a coverage gap.

What to do: If you lose Medicaid as a parent, a qualifying life event (loss of coverage) triggers a Special Enrollment Period (SEP) on the ACA Marketplace. You typically have 60 days from the loss of coverage to enroll. Advance Premium Tax Credits (APTCs) are available for households between 100% and 400% of FPL — and temporarily above that threshold under current law. Visit healthcare.gov or call 1-800-318-2596.

5. Adults in Non-Expansion States Who Gained Coverage Through Workarounds

Eleven states have not adopted Medicaid expansion as of 2026. In some of these states, limited coverage pathways exist through Section 1115 demonstration waivers or targeted eligibility categories. The OBBBA's proposed changes to waiver approval processes and enhanced match rates could eliminate these limited pathways, leaving adults in the coverage gap — earning too much for traditional Medicaid but too little for ACA Marketplace subsidies (below 100% of FPL in non-expansion states).

What to do: FQHCs, free clinics, and state pharmaceutical assistance programs remain available regardless of Medicaid status. Some non-expansion states have state-funded programs for specific conditions (HIV, tuberculosis, family planning). Contact your state health department's Medicaid office directly to understand what may remain available.

If You Lose Medicaid: A Practical Roadmap

Step 1 — Confirm Your Loss of Coverage in Writing Your state Medicaid agency is required to send written notice before terminating coverage. Keep this notice — it is your documentation for triggering an SEP on the ACA Marketplace.

Step 2 — Check ACA Marketplace Eligibility Visit healthcare.gov or your state-based Marketplace. Loss of Medicaid is a qualifying life event. You have 60 days. Households between 100% and 400% of FPL (and currently above, under extended provisions) may be eligible for APTCs that reduce monthly premiums significantly.

Step 3 — Locate a Federally Qualified Health Center FQHCs are required by federal law to serve all patients regardless of ability to pay, using a sliding-fee scale based on income. They provide primary care, dental, behavioral health, and pharmacy services. Use findahealthcenter.hrsa.gov.

Step 4 — Apply for Prescription Assistance If you lose coverage and cannot afford medications, contact the manufacturer directly or use NeedyMeds.org. Many brand-name medications have PAPs for uninsured patients. Generic medications are available at low cost through programs like GoodRx and Mark Cuban's Cost Plus Drugs (costplusdrugs.com).

Step 5 — Contact a Navigator or Certified Application Counselor Free, unbiased enrollment help is available through ACA Navigators funded by HHS. Find one at localhelp.healthcare.gov. Navigators cannot charge fees and are trained to identify all programs that may be available to your household.

If you submit any form or inquiry for assistance, you may be contacted by phone, email, or text. Standard message and data rates may apply. You may opt out at any time.

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Last reviewed: May 2026