The policy landscape for child and family health has undergone a dramatic transformation following the passage of H.R. 1, the budget reconciliation bill known as the One Big Beautiful Bill Act, and related policy changes enacted during the first year of the Trump administration. As we enter the second year of this administration, the Georgetown University Center for Children and Families is dedicating more of our time and attention to monitoring how these policies are being implemented, tracking the impact and examining state responses.
Our researchers will continue to conduct quantitative analysis through 50-state data trackers, policy analysis and research. We will continue to inform readers when early warning signs indicate policies are causing harm and make recommendations to soften the impact on vulnerable children, families and individuals. This blog outlines some of our top priority areas of focus for 2026.
HR 1 Medicaid Cuts and New Administrative Barriers
Monitoring Medicaid Cuts
H.R. 1 enacted the largest reductions to Medicaid in the program’s history—nearly $1 trillion in cuts representing approximately 11% of total program spending. Medicaid sustained the largest share of cuts in the reconciliation package, which simultaneously tripled Immigration and Customs Enforcement (ICE) funding and extended tax provisions that disproportionately benefit higher-income households. Medicaid, which covers nearly half of children in the country, has been proven to be a sound investment in children’s health and economic prospects into adulthood. H.R. 1 is a short-sighted and harmful approach that undermines our nation’s future while using more of the federal budget to ramp up ICE’s budget to terrify children and their parents.
The legislation shifts responsibility to governors and state legislatures to figure out how to fill the budget holes, creating significant variation in how cuts will affect people covered by Medicaid across states.
Tracking Work Reporting Requirements and Renewals
CCF will be closely following the H.R. 1-mandated work reporting requirements and semi-annual renewals for Medicaid expansion states. States are on a very compressed timeline to operationalize these new administrative barriers by the end of the year. The imposition of work reporting requirements represents one of the most consequential policy changes in H.R. 1. Implementing work requirements will be a heavy lift, and early estimates suggest they will result in millions of people losing coverage, primarily due to administrative barriers rather than actual failure to meet work requirements—a pattern documented when Arkansas put work reporting requirements in place in 2018 during the first Trump Administration. Nebraska has positioned itself as the first state to implement H.R. 1 mandated work requirements, with terminations scheduled to begin May 1, 2026—notably far ahead of the already tight federal deadline and before CMS has issued a final rule on the provision, which is expected in June. This compressed timeline for states raises significant concerns about procedural safeguards and the protection of exempt populations, including: parents and caretakers of children under 14, individuals with disabilities, students and those in job training programs and medically frail individuals to name a few.
Following the enactment of H.R. 1 last year, CCF launched a H.R. 1 State Readiness Tracker. A quick review shows how much work states have ahead of them and the clock is ticking. The tracker assesses state’s readiness based on eight metrics that pertain to their eligibility and enrollment systems: call center wait times; call abandonment rates; applications processed in over 30 days; the overall renewal rate; the ex parte (automated) renewal rate; the share of enrollees disenrolled at renewal; the procedural disenrollment rate; and the share of pending renewals. We pointed out that states were already having trouble keeping up with their eligibility and enrollment administrative workload and adding work reporting requirements, six-month renewals, and mandatory cost sharing requirements for adults in the expansion population will only exacerbate the situation.
Next month, CCF will add a comprehensive 50-state Medicaid enrollment tracker to provide timely data on enrollment trends for children and adults. CCF researchers are also developing a comprehensive public database and tracking system to monitor implementation costs and policy choices states make as they implement work reporting requirements.
Addressing Rising Child Uninsured Rates and Chilling Impact of Immigration Policy
Improving child health coverage is central to CCF’s mission, making recent policy developments that will lead to more uninsured children particularly concerning. In December 2025, CCF submitted detailed comments to the Department of Homeland Security on the proposed “public charge” rule changes. This regulation substantially expands discretion for immigration officials to deny status based on potential future use of public benefits, effectively overturning years of policy that protected access to healthcare and nutrition programs especially for children.
The administration’s immigration policies combined with ICE’s extreme tactics are creating what researchers term a “chilling effect”—eligible families avoiding public benefit programs and seeking out care when sick or injured due to fear of immigration consequences for family members. One in four children in the United States lives in a mixed-status family, where household members have different immigration statuses. The vast majority of children in these families (97%) are citizens.
Additionally, we have drawn attention to the unprecedented and illegal Medicaid data-sharing arrangement between the U.S. Department of Health and Human Services and ICE. ICE is accessing Medicaid enrollee data with limitations in states that sued to block the arrangement. If hospitals inform people that their Emergency Medicaid information will be shared with ICE, it is foreseeable that many immigrants would simply stop getting emergency medical treatment. Half of Emergency Medicaid cases are for the delivery of U.S. citizen babies. In this CNN-KFF article, my colleague Leo Cuello posed the question: “Do we want these mothers avoiding the hospital when they go into labor?” Additionally, we have drawn attention to the fact this data-sharing is likely to deter mixed-status families from enrolling eligible children, again most of whom are U.S. citizens.
CCF will continue tracking the rate of uninsured children in states across the country and release our annual state-by-state child health coverage report this fall. Our initial analysis of the public charge changes alone estimates the child uninsured rate could eventually increase by more than 25% due to the chilling effect, with the vast majority of newly uninsured children being U.S. citizens. Healthcare providers are reporting increased appointment cancellations and families avoiding emergency care due to fear of leaving their homes and the presence of ICE agents in the hospitals. School attendance has declined in communities with heightened ICE activity, with documented negative impacts on children’s mental health and overall family wellbeing that will persist for years. One of our newest colleagues, Steven Lopez will be doing in-depth research on the impact of the “chilling effect” on mixed-status families.
The human cost of these policy changes are far-reaching. Recent ICE actions in Minnesota illustrate another threat to child safety, health and well-being. Children are reportedly not attending school in large numbers. Schools are attempting to mitigate the impact on learning – Minneapolis Public Schools just extended the option for virtual learning through April due to ICE actions. Educators have expressed concerns about the widespread and traumatic long-term effects on children beyond missed school days. “We’ve seen increased anxiety among students, disruptions to attendance, and families questioning whether school remains a safe and predictable place for their children,” said Duluth Public Schools Superintendent John Magas as his school district joined others in a lawsuit aimed at restoring long-standing protections for students and schools from ICE encroachment. The photo of ICE agents arresting five-year old Liam Conejos Ramos, the boy in the blue bunny hat and a Spiderman backpack, focused national attention to the impact of ICE actions on children. Fortunately, Liam and his father were released from the South Texas Family Residential Center in Dilley, Texas and returned to Minnesota over the weekend but they should never have been detained in the first place. (A federal district court judge made his views about the constitutional violations involved in Liam’s case quite clear in his court order – it is worth a read.) The saga is far from over for Liam and his family as the Department of Homeland Security initiated expedited deportation proceedings, according to the Ramos family lawyer. A fourth-grader from Columbia Heights was also released from the Dilley facility but her return was delayed due to a measles outbreak at the ICE detention facility—a public health concern that underscores another way that ICE actions can affect child health. The impact of the ongoing trauma on all children, whether they are directly affected or see their friends and classmates impacted, is hard to predict. But as my colleague Anne Dwyer pointed out – the US was already suffering from a crisis in child and adolescent mental health.
Protection of Children from Preventable Diseases is Under Threat
The upending of the childhood vaccination schedule that reduced the recommended immunizations from 18 to 11 will have far-reaching consequences. CMS also made it harder to track the impact over the holidays by quietly removing four vaccine-related measures from mandatory Medicaid and CHIP quality reporting requirements – including child and adolescent immunization status. This policy change reduces transparency and accountability on an important public health measure for nearly half the children in the U.S. As my colleagues Kelly Whitener and Hannah Green have pointed out, these policy changes risk exposing children to preventable disease without any public input or plan to monitor the ramifications. Access to vaccines – especially for lower-income or uninsured children may suffer.
CCF will continue to provide rigorous, evidence-based analysis of all of the policies mentioned above and more. There is much to be done – watch what policymakers do, not what they say.