The 80 Million Podcast

Authors: Nick Bath, Gayle Mauser and Allison OrrisEditors: Patti Boozang and Amanda EisenbergThis episode of The 80 Million Podcast is hosted by Patti Boozang, Manatt Health Senior Managing Director and 80 Million editor. She is joined by her Manatt Health colleagues, partners Nick Bath and Allison Orris and director Gayle Mauser, to discuss what the midterm results mean for federal health policy and the future of the 2025 reconciliation law.tl;dr* Democrats’ midterm victories on Nov. 3, which spanned the Senate, House of Representatives and governor’s offices, reflect a mandate to address health care affordability— but not necessarily a unified policy agenda.* Repealing or modifying the 2025 reconciliation law will likely be an early priority, potentially through budget reconciliation, but any bill that passes is almost certain to be met with a presidential veto.* States can’t count on Congress for near-term relief. Medicaid work reporting requirements and more frequent eligibility redeterminations will still take effect on Jan. 1, 2027, and the administration retains powerful regulatory tools to continue advancing its health policy agenda.* For the first time since 2010, most governors will be Democrats, potentially signaling greater action and innovation on health care policy at the state level. Those states with new Democratic trifectas may be able to soften the law’s impact, but even they will be limited by the constraints of federal laws that will not change in the near-term. Governors facing divided state legislatures may turn more heavily to executive and waiver authorities.The 80 Million ImpactThe midterm elections shifted power in Washington, but they didn’t change the reality facing Medicaid. The 2025 reconciliation law remains in effect, the Trump administration still controls the executive branch and states are weeks away from implementing the law’s biggest coverage provisions.For Democrats, the results represent a significant political victory, but it’s a tactical win rather than a mandate to deliver a particular health care agenda. The challenge for Democrats now is turning voter frustration about growing barriers to accessing and affording health care into a health care platform — while balancing demands for oversight and the ability to govern. The next few months will begin with organizing the new Congress and reshaping key committees, including Energy and Commerce, Ways and Means, Education and Workforce, and Senate Finance. Hearings and legislative markups are expected to pick up around February, although House leadership may move sooner on messaging bills to repeal the 2025 reconciliation law’s health care cuts and extend the Affordable Care Act (ACA)’s enhanced premium tax credits.Repealing or reversing portions of the 2025 reconciliation law, particularly its Medicaid provisions, is likely to be a central priority for the incoming Congress. Budget reconciliation could offer a legislative vehicle to do this without needing bipartisan support in the Senate, but Democrats first need to agree on priorities and establish a budget resolution with instructions for committees. Even if they move quickly, President Trump retains veto authority.Indeed, the Trump administration retains significant authority to continue to shape Medicaid through executive action, including regulations and Section 1115 waiver decisions. The Centers for Medicare & Medicaid Services (CMS) is expected to prioritize finalizing rules on provider taxes and state-directed payments, as well as new Section 1115 budget neutrality rules. These policies will further impact how states finance and manage their Medicaid programs, posing constraints on new state leadership considering state-level reforms.Program integrity will also remain a focus. The administration’s actions to siphon Medicaid funding in targeted states based on claims of fraud, waste, and abuse could accelerate. Increased Congressional oversight is likely to scrutinize these actions, but it won’t necessarily stop the administration from pursuing them.For states, the 2025 reconciliation law still requires them to implement work reporting requirements, more frequent eligibility redeterminations and other eligibility changes by Jan. 1, 2027. The potential for ongoing appeals of the recent Massachusetts v. Oz decision, which vacated a provision of the federal work requirement rule, adds another layer of uncertainty. States must reconcile the ruling and potential appeals with implementation plans already underway.Simply put, the timelines for Congressional action and state implementation don’t align.States Have Different Paths ForwardDemocrats will hold a majority of governorships for the first time in 16 years, with victories in Georgia, Iowa, Nevada, Ohio and Texas, but the legislative makeup in their states will dictate how much change incoming governors can drive.States with Democratic trifectas will have greater flexibility to pursue coverage protections, affordability initiatives, and potentially soften the effects of the 2025 reconciliation law. Wisconsin is one state to watch, given the change in its legislature and the governor’s interest in implementing a public health insurance option. Other incoming Democratic governors will need to negotiate with one or more legislative chambers held by Republicans, which could limit their ability to advance bold reforms legislatively, while potentially increasing the importance of executive action and federal waiver authority. Republican-led states may move in the opposite direction, pursuing additional policies that make Medicaid coverage harder to access and maintain.The Bottom LineThe midterms created new opportunities for Democrats to challenge the 2025 reconciliation law but not immediate relief to Medicaid programs or the people who rely on them. Congress will need time to organize and develop a legislative strategy, while the administration retains powerful regulatory and administrative tools. Meanwhile, states must continue implementing provisions under the 2025 reconciliation law amid legal uncertainty and leadership transitions.Looking toward 2028, the broader question is whether Democrats can turn their electoral mandate into a durable health care agenda that addresses affordability, coverage and costs across the system. States may play an important role in that effort, particularly as they look for new approaches to cost containment and coverage within the narrower policy and financing options left by the 2025 reconciliation law.Listen to the full episode of The 80 Million Podcast to hear what the midterm results mean for the 2025 reconciliation law, how states should prepare for Jan. 1, 2027, implementation, and what to expect from Congress and the Trump administration. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit 80million.substack.com

This episode is hosted by Patti Boozang, Manatt Health Senior Managing Director and 80 Million editor. She is joined by MassHealth Chief Operating Officer Elizabeth LaMontagne, Massachusetts’ Health Care For All Deputy Executive Director Ashley Blackburn and Manatt Health Partner Kinda Serafi to discuss what implementation looks like on the ground — and what states are doing to mitigate harm.Authors: Ashley Blackburn, Elizabeth LaMontagne and Kinda SerafiEditors: Patti Boozang and Amanda Eisenbergtl;dr* Medicaid work reporting requirements take effect Jan. 1, 2027, creating a complex new set of eligibility and verification rules for states to implement.* About 5.7 million people nationally are projected to lose coverage by 2034 due to new work reporting requirements and six-month eligibility checks. MassHealth, the Commonwealth of Massachusetts’ Medicaid program, estimates up to 175,000 residents could lose coverage because of work requirements and six-month eligibility checks.* Massachusetts is partnering with community organizations, like Health Care for All Massachusetts, using data to identify people who qualify for exemptions and preparing to address problems as they arise — work that will need to continue well beyond the initial launch.The 80 Million ImpactStarting Jan. 1, 2027, states must implement new federal work and community engagement requirements for certain adult Medicaid enrollees. What some would describe as a straightforward new eligibility requirement — demonstrating 80 hours a month of work or other qualifying activities or establishing an exemption — is anything but.States must build new eligibility processes, update technology systems, train staff on and help members navigate complicated rules. It’s logistically challenging and the consequences of getting it wrong are significant: People who remain eligible for coverage could lose their access to health care because they misunderstood a notice, missed a deadline or struggled to document an exemption.One of the biggest challenges is distinguishing Medicaid enrollees who must meet work reporting requirements from those who qualify for an exemption. Medical frailty is particularly difficult to assess. Having a serious medical condition like cancer doesn’t automatically qualify someone for an exemption; states must determine whether that condition affects a person’s ability to meet the requirements, often with incomplete information.Massachusetts is trying to reduce the burden on enrollees and applicants by using existing data to identify people who are exempt or already compliant. However, not everyone can be identified automatically — making clear consumer communication and accessible assistance essential.MassHealth is working closely with community organizations and providers to help members understand what the new rules mean for them. Health Care for All Massachusetts has expanded its community-based partner network from about 30 organizations to nearly 50, building on lessons from the state’s post-pandemic Medicaid renewal effort.Massachusetts found that people often turn to trusted local organizations, health centers and help lines before they turn to a state agency. Still, those partners need the training and resources on these new and complicated requirements to help members navigate the process — which is where states can step in.Massachusetts estimates that up to 175,000 residents could lose coverage due to work reporting requirements and six-monthly eligibility checks. Nationally, Manatt Health estimates nearly one in 10 Medicaid enrollees nationwide may lose coverage from such changes.A large swath of those losses will stem from administrative hurdles, not because people fail to meet the requirements, and those challenges will grow in 2028 when more frequent renewals and tighter limits on self-attestation add further demands. States will need to track enrollment patterns, listen to community partners and respond quickly when problems arise, rather than wait months for the data to tell the full story.The Bottom LineListen to the full episode of The 80 Million Podcast to hear how Massachusetts is preparing, where the biggest risks lie and what other states can learn from its approach. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit 80million.substack.com

In this episode of The 80 Million Podcast, Manatt Health Senior Managing Director and 80 Million Editor Patti Boozang speaks with Professor of the Practice at Princeton University’s School of Public and International Affairs and State Health and Value Strategies Director Heather Howard and Manatt Health Partner Allison Orris about what H.R. 1 implementation looks like on the ground as states build against a moving target and work to minimize avoidable coverage losses.Authors: Heather Howard and Allison OrrisEditors: Patti Boozang and Amanda Eisenbergtl;dr* Last year’s reconciliation law made unprecedented cuts to Medicaid that will shape the program and our health care ecosystem for years to come. States are building against a moving target even as their implementation efforts are well underway — such as stripping Medicaid coverage from certain lawfully present immigrants as required by H.R. 1 and operationalizing work reporting requirements, more frequent eligibility redeterminations and limits on retroactive eligibility that take effect in January 2027.* States are adapting their systems and policies to major, late-breaking policy changes in the administration’s work reporting requirements rule. At the same time, they are making critical policy and budget decisions as federal rules governing Section 1115 demonstrations, provider taxes, and state-directed payments continue to evolve ahead of key implementation deadlines.* Coverage losses are a major part of the story. Rising uncompensated care and financing changes made by H.R. 1 will also put pressure on Medicaid agencies, providers and state budgets in ways that will be broadly felt beyond people enrolled in Medicaid.* This next year will generate critical evidence. Hard data could take longer but providers will soon see evidence of rising coverage losses and uncompensated care. Other early indicators — most especially enrollees’ experiences navigating new systems — can help policymakers understand how implementation is working in practice.The 80 Million ImpactH.R. 1’s Medicaid changes are arriving in waves, but states are already feeling the cumulative pressure as they prepare to implement various provisions of the law and consider how they will respond to the fallout from rising uninsurance, uncompensated care and budgetary constraints.The law cut nearly $1 trillion in federal Medicaid funding over the next decade, making major structural changes to significant parts of how the program operates. Although some of its biggest provisions do not take effect until 2027 or later — and federal guidance on some provisions is still pending — states have been working to implement these changes at record speed because of tight timelines and high stakes for their enrollees. Getting ready to implement the new Medicaid work reporting requirement in states that expanded Medicaid has garnered significant attention over the last year.There are other near-term changes that states have also been preparing for by updating eligibility systems, communicating with enrollees and providers, and by forecasting how changes will impact their budgets.Beginning Oct. 1, federal Medicaid funding was eliminated for certain categories of lawfully present immigrants. The effects could extend beyond the individuals who lose eligibility. Confusion about the new rules, coupled with new public charge rules, may discourage eligible family members, including children, from enrolling or staying covered. At the same time, the federal matching rate to help Medicaid expansion states cover the cost of emergency Medicaid services for some immigrants who are not eligible for Medicaid was reduced.More changes will arrive in January. In addition to work reporting requirements, Medicaid expansion adults will move from annual to twice-yearly eligibility redeterminations, creating two opportunities each year for eligible people to lose coverage because of paperwork problems or other administrative issues. Retroactive eligibility will also shrink from up to 90 days before application to 30 days for the expansion population and 60 days for other eligibility groups. Together, these policies could mean more medical debt for consumers and more uncompensated care for providers, who will bear the brunt of Medicaid cuts that will take effect later in 2027 and in 2028.States Are Implementing. The Rules Are Changing.States have taken steps to prepare for provisions in H.R. 1, which became law in July 2025, yet they didn’t receive firm implementation direction on work reporting requirements, for example, until June 2026. The Centers for Medicare & Medicaid Services’ interim final rule, which included a narrower reading of the medical frailty exemption, changed key policy elements states had already been building their systems, workflows and policies around.States pivoted quickly but are still awaiting guidance in other areas that will influence their programmatic plans and budget outlooks. For example, states are preparing for new standards governing Section 1115 waivers beginning in 2027 while awaiting final federal policy. Once finalized in 2027, rules governing provider taxes and state-directed payments will further reshape the financing and reimbursement tools states use to support Medicaid, likely constraining state budgets in ways that will force hard choices in years to come.For state agencies, waiting for perfect clarity is not an option. Systems must be built, notices tested, budgets written and staff trained. That creates a difficult balance: implement quickly enough to meet federal deadlines while minimizing avoidable coverage losses among people who remain eligible.The Bottom LineEarly evidence will be crucial as certain H.R. 1 provisions take effect on Jan. 1, 2027. States should be watching not only how many people lose Medicaid coverage, but also why they lose it, who successfully receives exemptions from work reporting requirements, where providers begin reporting increases in uncompensated care and how they weather those changes.That data — and the experiences of Medicaid enrollees themselves — can help identify avoidable losses caused by administrative friction. With implementation already underway, policymakers will not have the luxury of waiting years to understand the consequences.And those consequences are likely to spill beyond the people who are most directly impacted by the headline-grabbing Medicaid eligibility changes. Chaos and confusion about new requirements that impact only some enrollees will could affect the entire Medicaid population as call centers and eligibility workers respond to enrollee and applicant needs. Similarly, rising uncompensated care will likely lead to crowded emergency rooms and financially strapped providers, potentially weakening the health care systems that all of us rely on in our communities.Listen to the full conversation of The 80 Million Podcast on Spotify, Apple Podcasts or wherever you get your podcasts to hear how states are preparing for H.R. 1 amid evolving federal guidance, how the law’s effects could extend beyond those directly subject to its eligibility requirements and what early evidence will reveal about implementation in practice.And don’t forget to subscribe to The 80 Million Podcast.The 80 Million Editor Patti Boozang will moderate a Manatt Health webinar on Monday, Oct. 26 examining how the midterm elections could shape health care policies and priorities. To register or for more information, click here. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit 80million.substack.com

The Affordable Care Act (ACA) fundamentally changed American health care —  expanding coverage, establishing consumer protections that are now broadly expected, and helping cement the idea that access to health care is a basic human need rather than a privilege tied to health status, gender or income.The next challenge is no longer just whether people have coverage, but whether they can afford to get it, keep it and use it. Rising premiums, deductibles, cost-sharing and administrative barriers are straining people across Medicaid, the ACA Marketplaces, Medicare and employer-sponsored insurance.Fixing American health care will require looking across the whole system: reducing friction for patients and providers, rebuilding a durable federal floor for coverage and access, resisting efforts to retreat to a pre-ACA coverage framework, supporting state innovation, and accepting that meaningful reform will require mutual sacrifice across the health care ecosystem.The challenge before us is creating a health care system that is affordable, usable and sustainable for patients, providers, employers and taxpayers alike — wherever they live and whatever their income, gender, race or age. We have a great deal of work to do. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit 80million.substack.com

High-cost therapies like cell and gene therapies could transform care for Medicaid beneficiaries with serious conditions, but their upfront prices — often $500,000 to $5 million per patient — do not fit a financing system built around predictable, chronic-care spending. The pressure will only grow as the pipeline expands, eligible populations broaden and treatments become easier to administer. Medicaid’s fixed budgets, enrollment churn and limited data infrastructure make it hard to pay for these therapies at scale or capture their long-term value. Outcomes-based payment and Centers for Medicare & Medicaid Services (CMS) models are important near-term tools, but they are not enough. Durable access will require bolder federal financing solutions such as reinsurance, risk pooling or a dedicated funding stream for transformative therapies. Listen to the full conversation on Spotify, Apple Podcasts, or wherever you get your podcasts to hear Patti Boozang, Terry Cothran and Ross Margulies unpack the promise of curative therapies, the limits of Medicaid’s current financing model and the policy choices needed to make access real. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit 80million.substack.com

Americans are rapidly aging, which is accelerating the demand for the long-term services and supports (LTSS) necessary to their care, as well as the care of a diverse range of children and adults with disabilities. Medicaid is the primary payer for LTSS. Since the early 1980s, that coverage has included home and community-based services (HCBS), which have proven better for health, less expensive and what most people prefer over institutional care. HCBS now make up almost two-thirds of long-term services and support spending, double the rate in 2001.Because HCBS are an optional benefit under Medicaid, states facing fiscal crises can limit access, including through enrollment caps and waiting lists. Today more than 600,000 people are waiting for care across 41 states.With states facing nearly $1 trillion in federal Medicaid funding cuts over the next decade from H.R. 1 and a drumbeat of recent statements from federal leaders questioning the integrity and purpose of HCBS, the fragile infrastructure that keeps people out of nursing homes is at risk — bringing greater urgency to the imperative for change. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit 80million.substack.com

The scale of federal retrenchment is no longer theoretical. In Massachusetts alone, the state is bracing for an estimated $3.5 billion annual loss in federal Medicaid funding once H.R. 1 is fully implemented, against a total Medicaid budget of over $20 billion. Even with aggressive mitigation, the state could still see about 300,000 residents lose coverage.The idea that H.R. 1 simply “right-sizes” Medicaid while protecting the most vulnerable is already breaking down. Children, pregnant women, and people with disabilities are already feeling the effects through fear-driven disenrollment, mounting pressure on rural maternity care, and tighter scrutiny of home- and community-based services.States cannot replace lost federal dollars, but they are not standing still. This episode of The 80 Million Podcast shows how state leaders are investing in trusted, community-based outreach to keep eligible people covered, tackling affordability, shoring up providers and leading through the maelstrom. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit 80million.substack.com

The evidence that addressing social needs like food and transportation improves health outcomes and reduces Medicaid costs is no longer theoretical. We’ve seen recent data from two efforts: North Carolina’s Healthy Opportunities Pilots (HOP) generated $164 in savings per member per month, according to a new, multiyear evaluation of 31,000 Medicaid enrollees by the Sheps Center at University of North Carolina. The Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities model showed 3%–4% reductions in total cost of care through screening and navigation alone.Payment remains a major structural barrier. Most of this work — outreach, navigation and coordination — has no billing code under fee for service. Scaling requires value-based arrangements with real teeth, not the “value veneers” that occupy value-based care real estate without changing care delivery. Waymark, a Medicaid-focused care delivery company, addresses this by pairing AI-enabled community-based care teams with value-based contracts designed to measure impact and align payment with proven intervention.States don’t need to wait for federal action. Managed Medicaid contracts allowing for accountable programs that meet social and clinical needs, using in-lieu-of services authority, and directing rural health transformation dollars toward this infrastructure are all available now. Still, permanent scale will require Congress to move this work from waiver territory into the core Medicaid benefit.Rajaie Batniji, Patti Boozang and Mandy Cohen explore what the latest evidence on addressing social needs in Medicaid means for policy and practice in this week’s 80 Million Podcast. The discussion examines why the case for action is stronger than ever, what it takes to scale these interventions, and where states can move now. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit 80million.substack.com

State Medicaid programs are under extraordinary pressure as they navigate federal funding uncertainty, H.R. 1 implementation, and health care cost growth that consistently outpaces both inflation and state revenue growth. States have myriad technology vendors pitching solutions to help alleviate those burdens, particularly around helping drive down the costs associated with certain clinical conditions and administrative functions. These technology solutions, increasingly, are AI powered and promise to be the differentiator for patients and Medicaid budgets alike.It can be daunting for state Medicaid leaders to evaluate which technologies deliver, where there are risks, and the types of structural changes that are needed for innovation to benefit the people Medicaid serves rather than the vendors selling to it.In Episode 3 of The 80 Million Podcast, host and 80 Million editor Patti Boozang speaks with Caroline Pearson, executive director of the Peterson Health Technology Institute (PHTI), and Jared Augenstein, senior managing director at Manatt Health, about what Medicaid leaders should believe — and question — about the explosion of artificial intelligence (AI) and digital health solutions entering the market. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit 80million.substack.com

Innovate or die: That’s the conversation health systems are having as they navigate tightening finances due to new federal policy in Medicaid, including H.R. 1, a national health care affordability crisis, rising patient acuity and a workforce depleted by burnout.  Hospital at Home may signal a paradigm shift among hospital systems driven by “losing less money.” That’s good news for Medicaid. 80 Million Editor Patti Boozang sat down with UMass Memorial Health CEO Dr. Eric Dickson and Manatt Health’s Tom Robertson to explore what real innovation looks like in a hard operating environment. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit 80million.substack.com