The drop in Medicaid/CHIP enrollment means more children are likely becoming uninsured.
We spend a lot of our time at the Georgetown University Center for Children and Families monitoring child and adult Medicaid and the Children’s Health Insurance Program (CHIP) health coverage trends. The latest federal CMS data confirms that child enrollment in these programs dropped by 1.5 million since President Trump took office in January 2025. The CMS enrollment data covers January 2025 to January 2026. State data we’re tracking suggests that number could be 1.8 million as of this writing and will soon reach 2 million. This is very problematic – as when the number of children enrolled in Medicaid goes down the uninsured rate tends to go up – because most children who lose Medicaid and/or CHIP remain eligible and/or don’t have other sources of affordable coverage available to them.
I will come back to this subject in the months ahead – but bear in mind that these enrollment declines are happening largely prior to the impacts of H.R. 1 kicking in – including historic cuts and more red tape that will cause coverage losses. One reason though that is likely to account for some of this child enrollment decline – as we’ve discussed before – is the “chilling effect” whereby parents of citizen children living in mixed status families are too fearful of deportation and other negative consequences if they share contact information.
Medicaid work reporting requirements don’t work – except to take away coverage from people who need it – and they are coming to a theater near you with sneak previews in Nebraska and Montana.
One of the signature policies of H.R. 1, also known as the One Big Beautiful Bill Act, is the work reporting requirement. Forty-three states will have to implement these onerous requirements starting January 1, 2027, but three states are starting early. That includes Nebraska, which began last Friday, May 1 – a full 8 months early and before the federal government has issued official regulatory guidance. Montana plans to start enforcing work reporting requirements on July 1 and Iowa is scheduled to implement them on December 1. In addition, Arkansas is planning a “soft launch” sometime in 2026.
It’s concerning that Nebraska is moving so fast. Implementing work reporting requirements can be costly and time consuming. After all, the state will have to start checking in regularly with the 70,000 adults in the expansion population. Yet Nebraska has not hired any additional workers or outside vendors and has not expanded its tech capacity or call center capacity to deal with this new workload.
Our friends in Nebraska worry not just about this lack of state investment, but also about the lack of outreach to the people affected and inadequate training of caseworkers. State materials that have come out have been extremely complicated and vague, including an incomplete list of possible exemptions. People are waiting an hour to talk to someone at the call center only, in some cases, to be giving the wrong information. Sarah Maresh from Nebraska Appleseed recently shared a chilling story of a parent with multiple serious health conditions who is blind and had a port and was told erroneously by a state worker that she would have to comply with the work requirement. In preparation for being uninsured, the parent made an appointment for the port to be removed, eventually cancelling the appointment when the parent spent more time seeking help and learned that she would be exempt. These kinds of stories underscore that the state should “press pause.”
Beyond its lack of preparation, Nebraska also has not committed to providing any data on the impact of the new policy nor is any data publicly available on their website. Despite claims of imparting “radical transparency” to HHS by Secretary Kennedy, the feds have shared nothing to date about data that states will have to report and/or that CMS will make available to the public. Questions such as how many people are losing coverage, how many are being disenrolled for procedural reasons, how many are getting employer-sponsored insurance and how many are getting exemptions, etc. are critical. During the post-pandemic Medicaid unwinding data proved extremely helpful to identify problems and, in some cases, address them.
We had the unwinding data because Congress required all states to report certain metrics and share them. Right now, we don’t have final federal guidance on how states should implement the work reporting requirements – much less what sort of data they should report.
A consistent rhetorical bias has developed since discussions about passing work reporting requirements started in earnest in 2025 — proponents do NOT like to mention that parents (and therefore children) may be impacted. Misleading stereotypes of who would be impacted abound. This is evident in Nebraska and Montana as well. Nebraska defines the impacted expansion population as encompassing all “able-bodied adults” making less than 138% of the federal policy level. In fact, very low-income parents in every state who were eligible before the Affordable Care Act passed (in Nebraska that is those earning less than 58% FPL for a family of three) are exempt regardless of the age of their children. But Nebraska doesn’t mention that in its documents. Neither does Montana, which plans to launch its work requirements in July. Both states just say that all parents with children under age 14 are exempt — but it is not that simple as our recent blog pointed out. And Nebraska does NOT even mention that any parents are exempt in its one-page flyer.
Moreover, many of those impacted by work reporting requirements will have chronic conditions or worse – such as cancer, depression, hypertension – but don’t meet the federal definition of disabled.
All parents with children under age 14 are exempt as well as the “Section 1931” parents described above as our recent blog on which parents will be exempt explains.
We’ve launched a Nebraska tracker to monitor many aspects of work reporting requirements including enrollment changes (although Nebraska’s data is very lagged), policy choices, state eligibility system metrics such as call center wait time etc. and administrative costs. We will develop similar trackers for all 43 states (including DC) subjected to the work reporting federal mandate, and they will be available on our website shortly.
The clouds are starting to gather; our CCF team will continue to do our very best to keep you informed on what’s happening out there for the millions of Americans who rely on Medicaid for their health coverage.