It’s been nearly a year since H.R.1 was signed into law, enacting the largest Medicaid cuts in history and setting off a scramble in state capitals to respond. Back in March, we took a look at how ten state legislatures were grappling with the impending budget holes and policies created by H.R.1. Now that most 2026 state legislative sessions have wrapped up, we’re taking another look at how state lawmakers responded.
Attempts by state legislatures to codify provisions of H.R. 1 in state code has perhaps been the most prolific response we’ve seen across states. In many of these codification bills, state legislators also took the opportunity to go further than the already harmful provisions of H.R. 1. Kentucky’s House Bill 2, vetoed by the Governor but overridden by the legislature, requires the state to adopt cost-sharing for certain services for Medicaid expansion individuals higher than required in H.R. 1. North Carolina’s legislature passed a bill requiring adoption of Medicaid copayments at the highest allowable amounts for both traditional Medicaid enrollees and expansion enrollees, despite H.R. 1 mandating cost-sharing only for the expansion population. North Carolina, New Hampshire and Wyoming legislatures also passed laws that prohibit the use of self-attestation, also known as self-declaration, for making Medicaid eligibility determinations, even though its continued use is explicitly allowable in H.R. 1.
Several state legislatures adopted more restrictive and burdensome Medicaid work reporting requirement policies. North Carolina, Indiana, and Idaho require a three-month lookback period at application, meaning new Medicaid applicants must show compliance with work or similar activities for three full months before application, rather than the minimum of one month. New Hampshire and Indiana adopted quarterly compliance checks, with a three-month lookback period at each renewal and quarterly check, thereby doubling the state’s administrative burden and adding massive red tape for individuals.
Many of the H.R. 1 Medicaid provisions are intended to roll back Medicaid expansion significantly. Legislators in multiple states considered its enactment an opportunity to revisit Medicaid expansion altogether. In Idaho, legislators introduced a bill to repeal their voter-enacted expansion, but it never made it out of committee (this is not the first time the Idaho legislature has attempted to repeal expansion). In Oklahoma, where expansion was also voter-enacted, lawmakers introduced but did not enact a measure which, if it had passed, would have placed Medicaid expansion back on the ballot in the fall and asked voters to decide whether to remove expansion from the state constitution.
In the wake of H.R. 1’s restrictions on immigrant eligibility for Medicaid – and amid the budget pressures the law creates for states – many state legislatures have enacted restrictions to immigrant eligibility that go beyond H.R. 1 or cuts to Medicaid programs for immigrant groups. Louisiana and Wyoming legislatures passed bills that will limit Medicaid applicants to a single reasonable opportunity period to provide documents to verify their citizenship or immigration status, and failure to verify in this single period bars any future opportunities to verify status for the purposes of Medicaid application. North Carolina’s legislature ended optional Medicaid coverage for lawfully residing children and pregnant immigrants without a five-year waiting period, also known as the ICHIA option. Colorado’s legislature, faced with a $1.5 billion budget deficit that’s likely to worsen with H.R. 1 cuts, passed a bill to limit benefits and cap child enrollment in their Cover All Coloradans program, a program that provides health care coverage to low-income children and pregnant people regardless of immigration status. This measure is expected to save $16 million in the next fiscal year and $30 million annually in future years.
Budget pressures from H.R. 1 also meant state lawmakers were faced with tough decisions about how to cut costs – and often looked to cut Medicaid provider rates and services. In Idaho, lawmakers approved a $22 million cut in fiscal year 2027 to Medicaid reimbursement rates for residential rehabilitation providers that help adults with disabilities live independently. This cut combined with a 4% Medicaid provider rate cut in 2025 amounts to a 10% rate reduction for these providers. In Colorado, in order to close a $1.5 billion budget gap, state lawmakers cut Medicaid provider rates by 2% and capped caregiver compensation for people who care for a family member with an intellectual or developmental disability, among other provisions. Colorado’s recent budget cuts compound reductions the Governor already made in mid-2025 — including halting provider rate increases and a $2.5 million cut to its Medicaid dental care program — to plug a $750 million deficit triggered by H.R. 1. In April 2026, Montana’s health department announced it would halt reimbursement for doula services in Medicaid (which lawmakers passed in 2025 and was set to start in 2026), citing a large gap in federal Medicaid funds, partly due to H.R. 1. The state health department later reversed course, moving ahead with doula coverage this year, but leaving Montana families wondering if Medicaid benefits remain on the chopping block.
Amid all these rollbacks and restrictions that threaten access to coverage for millions, there remains opportunities for states to protect and expand access to health coverage. Wisconsin’s legislature adopted the option to extend postpartum Medicaid coverage to a full 12-months, leaving Arkansas as the only state that has taken up that coverage option.The Kansas legislature fixed a long-standing drafting error in their state law, which will help ensure eligible kids can continue to access health coverage through the Children’s Health Insurance Program (by adjusting eligibility levels to keep pace with inflation, rather than stay tied to 250% of the 2008 federal poverty level). Nebraska’s legislature approved reimbursement for doula services in Medicaid. Maryland lawmakers passed the Maryland Protecting People with Disabilities Act, which seeks to protect individuals with intellectual or developmental disabilities from losing access to coverage for procedural reasons. Virginia’s budget, pending approval from the Governor, includes $150 million for state-level health care marketplace subsidies to temporarily mitigate the impact of the expiration of the Enhanced Premium Tax Credits. Lawmakers in Connecticut voted to extend the Governor’s $500 million emergency response fund, enacted during a 2025 special session to counter H.R. 1 cuts, which includes $110 million to offset increases in marketplace premiums from the expired enhanced tax credits and $2 million to support community health workers who help Connecticut residents navigate the cuts to Medicaid and nutrition assistance programs.
While not a comprehensive analysis of all state legislative activity this year, this reflects the wide variety of initial legislative responses to H.R. 1, and states have considerable work ahead as H.R. 1 cuts and work reporting requirements go into effect. States only just started to receive formal guidance from CMS on how these cuts and changes to Medicaid will actually be implemented. For more information about recent guidance and rules, see the blog by our colleague Leo Cuello about the proposed regulation on state-directed payments; Leo also shared an initial reaction to the work reporting requirements interim final rule; and Joan Alker and Edwin Park wrote about CMS’ guidance dramatically modifying and restricting the budget neutrality requirement for Section 1115 waivers. So far, guidance from CMS is going well beyond the statutory authority in H.R. 1, surprising many states who had already started preparing for changes based on contradictory and informal guidance. In many cases, the guidance is increasing the financial and administrative burden that states will face, and we anticipate seeing state legislatures grapple with these challenges for years to come.