The One Big Beautiful Bill Act could result in 23,000 to 44,000 fewer Medicaid expansion enrollments in Rhode Island, depending on the state’s mitigation efforts, according to a recent report by the Urban Institute.
Beginning Jan. 1, 2027, all Medicaid enrollees ages 19 to 65 are required to participate in 80 hours per month of community engagement, according to Erin Fuse Brown, a professor of health services, policy and practice and the director of the Health Policy and Law Lab. Community engagement includes enrollment in a work program or an education program, community service or work.
Medicaid will also no longer cover “asylees, refugees and victims of domestic abuse or trafficking,” who previously qualified after they had been U.S. residents for five years, Fuse added.
An October report by the Federal Compliance Advisory Group of the Rhode Island Executive Office of Health and Human Services estimated that approximately 24,600 Rhode Islanders will lose coverage under community engagement requirements. The report also estimated that around 9,000 individuals in Rhode Island will be impacted by the changes to eligible populations.
Jennifer Haley, a principal research associate in the health policy division at the Urban Institute, explained that her team used a micro-simulation model to determine how many Medicaid recipients in each state would be “compliant with or exempt from work requirements.”
The team developed a range for how many people in each state would lose their Medicaid coverage based on low, middle and high levels of state mitigation. These rates could be impacted by policies dictating how many months before applying an applicant must meet work requirements and states’ abilities to “perform these automatic exemptions and compliance checks,” among other policy decisions state officials could make, Haley said.
Regardless of how mitigation efforts are implemented, the researchers “project that millions of people will lose their coverage,” Haley said. But losses are twice as high under the low mitigation scenario compared to the high mitigation scenario, she explained.
Prior to the passage of this act, only two states had implemented work requirements for Medicaid benefits — and one of those states stopped its program, according to State Rep. Rebecca Kislak ’94 (D-Providence).
The One Big Beautiful Bill “cuts nearly $1 trillion from Medicaid, putting strain on state budgets and putting health care at risk for the 329,000 Rhode Islanders who rely on the program,” Noah Boucher, director of communications for Representative Seth Magaziner ’06 (D-R.I. 2), wrote in an email to The Herald.
“It’s going to cost a lot more money just to enforce those work requirements,” Kislak said.
Fuse Brown explained that the state will face a budget shortfall of $75 million without the federal funds, and may be forced to pay “tens of millions in additional costs to implement and administer the new Medicaid work requirements and revalidation requirements.”
She noted that R.I. hospitals “will see declining revenue” due to $150 million in cuts to provider taxes — which support Medicaid — and around a 21% decrease in Medicaid payments.
Experts and community leaders are working on finding ways to bridge the “revenue hole” created by the changes in provider taxes, said Hayden Rooke-Ley, a senior fellow at the School of Public Health.
Kerri White, director of public affairs at the EOHHS, wrote in an email to The Herald that Gov. Dan McKee’s fiscal year 2027 budget proposal includes a $10 million allotment to support state hospitals pertaining to the rise in uncompensated care, or medical care administered to those without insurance.
Kislak explained that Rhode Islanders who lose their insurance will be able to turn to emergency rooms for care, but “that’s an added cost to the health care system and a very expensive place to get health care.”
“At a time when access to affordable health coverage is under attack, we must support our hospitals, which are often the first line of defense,” McKee said at a Hasbro Children’s Hospital event on April 4.
Rooke-Ley suggested that Rhode Island could revise its affordability standards policy to alleviate requirements on “the most vulnerable hospitals.” He also suggested potentially moving away from private insurance intermediaries and collaborating with community organizations to “gather all the information necessary and set up processes for keeping people enrolled on Medicaid.”
White wrote that EOHHS will communicate with Rhode Islanders impacted by the Medicaid cuts in the upcoming weeks and months.
“When people don’t have health insurance, they get sicker, and hospitals get drained financially,” U.S. Sen. Sheldon Whitehouse (D-R.I.), who is a senior member of the Senate Finance Committee, said in a press release emailed to The Herald. “This bill will put serious pressure on Rhode Island’s health care system, and I’m doing everything in my power to fight it.”
The White House did not respond to a request for comment.
Kelly Ding is a senior staff writer for the community and culture beat. She is from College Station, TX and plans to concentrate in IAPA on the policy and governance track. In her free time, she loves to explore new coffee shops, curl up with a good book, and be a gym rat.
