Medicaid changes: Who loses coverage Oct. 1?

The change, which state Medicaid agencies are racing to carry out, is required under a sweeping tax and spending law, sometimes called H.R. 1 or the One Big Beautiful Bill Act, that was signed by President Donald Trump last year.

Here are five things to know about what’s changing on Thursday.

The Takeaways

1. People losing Medicaid coverage are legally in the United States

While Trump and Republican leaders promoted Medicaid provisions in the law as a way to remove undocumented immigrants from the program, the new restrictions affect certain groups of lawfully present immigrants who had legal access to the healthcare safety net program for low-income people.

“They were going about eliminating longstanding eligibility for lawfully residing immigrants,” said Edwin Park, a research professor at Georgetown University’s Center for Children and Families. 

Undocumented immigrants already weren’t eligible for comprehensive Medicaid.

Beginning Oct. 1, Medicaid eligibility will only be allowed for certain categories of immigrants: those who hold green cards as lawful permanent residents, Cuban and Haitian entrants, and people from certain Pacific Island nations that have special agreements with the United States. States also can continue coverage for certain lawfully residing children and pregnant people through Medicaid and CHIP, the Children’s Health Insurance Program.

Park said there are many others who will lose Medicaid eligibility because they are legally present immigrants who don’t fall into these categories. He said they include refugees, people granted asylum, certain victims of domestic violence or sex trafficking, and people with special immigrant visas from Iraq and Afghanistan. 

There is no good national estimate of how many people will lose Medicaid coverage this week under the Oct. 1 restrictions, Park said. 

“In general, if you're in one of these categories, there's a significant risk that you're going to end up uninsured, unfortunately,” Park said.

2. Where you live can determine whether you actually lose coverage

Because Medicaid is a joint program of state and federal governments, the impact will vary by state.

At a recent virtual town hall meeting for North Carolina residents receiving Medicaid, Melanie Bush, deputy secretary for North Carolina Medicaid, urged non-U.S. citizens who are losing their coverage to see their healthcare providers and get prescriptions refilled before the end of the month. 

"If you are a non-U.S. citizen and not part of one of these groups [keeping eligibility], you will lose your healthcare coverage through North Carolina Medicaid as of October 1st,” she warned. “This includes doctor visits, prescriptions, mental health, dental, and other services." 

She said those losing coverage may only be eligible for Emergency Medicaid, noting it only covers severe, emergency care – such as a heart attack, stroke, or serious accident.

Meanwhile, in Oregon, about 7,000 affected residents can move to the state’s Healthier Oregon program. 

“They will continue to be able to receive the same benefits and services that they currently receive,” said Vivian Levy, Oregon’s interim Medicaid director. “But obviously that does mean that federal funding to support those folks will not be available to the state anymore.”

3. Losing Medicaid can disrupt lifesaving treatment

Consider a Medicaid patient with kidney failure who relies on dialysis to stay alive.

“It’s a really catastrophic situation for these people,” said Miriam Godwin, vice president of health policy at the National Kidney Foundation.

Most people with kidney failure need outpatient dialysis about three days a week for about three to four hours at a time, she said. Dialysis filters wastes and excess fluid from the blood. 

But states differ on whether their Emergency Medicaid programs will cover maintenance dialysis as an emergency treatment.

In states where Emergency Medicaid doesn’t cover scheduled maintenance dialysis, a patient can end up repeatedly waiting until their condition deteriorates so much that they require emergency treatment. Only then, Godwin said, will they be able to go to an emergency department and receive dialysis and other medical treatments to stabilize their condition, before being discharged, then beginning the cycle again.

“It won’t keep you alive on a long-term basis,” Godwin said. “It’s a stop on the train to dying.”

It’s unclear how many people losing Medicaid coverage Oct. 1 are receiving dialysis. Officials with the Centers for Medicare and Medicaid Services did not respond to questions about how many states allow for coverage of scheduled maintenance dialysis under Emergency Medicaid.

4. The costs don’t disappear — they move

Patients, hospitals, safety-net providers, and states will face new costs that the federal government is no longer paying.

“Health centers are required to treat all patients, regardless of their insurance status,” said Joe Dunn, chief policy officer for the National Association of Community Health Centers, whose members provide affordable primary care at more than 17,000 sites nationwide. “For people who are going to fall off the Medicaid rolls, that's going to present challenges for sure.” 

He said that member health centers, which include Federally Qualified Health Centers, operate on “razor-thin margins.”  

Drishti Pillai, director of immigrant health policy at KFF, a nonprofit health policy research organization, said people who become uninsured may delay preventative or other care, while hospitals, providers, and states may face greater financial strain.

“There will be ripple effects on the workforce and economy,” Pillai said. “As more immigrants lose access to affordable coverage, it can lead to worse health outcomes, and ultimately that can impact productivity and increase the cost and exacerbate shortages in the U.S. workforce.”

5. Larger Medicaid changes are ahead

Thursday’s changes come as states prepare for far broader Medicaid changes that will begin in January. 

That’s when new work and community engagement rules will take effect for many adults and state Medicaid agencies will be required to do more frequent eligibility checks on Medicaid recipients. 

Shortly after the law passed last year, KFF, citing Congressional Budget Office estimates, wrote that its healthcare provisions were projected to result in 10 million more uninsured people in 2034 and reduce federal Medicaid spending by $911 billion between 2025 and 2034.

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