Medicaid directors sound the alarm on H.R. 1's sweeping coverage and funding impacts

At the National Association of Medicaid Directors (NAMD) 2026 conference in Maryland, state Medicaid officials painted a sobering picture of what H.R. 1 means for their programs. Work requirements kick in January 1, 2027, and states are scrambling — New Jersey and Illinois have already seen roughly 10,000 and 9,000 immigrants, respectively, lose coverage this month alone. Illinois projects up to 300,000 residents could ultimately lose coverage, alongside a potential $51 billion funding loss over the next decade.

The debate over Medicaid's role in rising costs was front and center, with conservative voices calling out cost-shifting to the federal government, while others argued Medicaid is the lowest-cost insurance available and that cuts risk collapsing safety-net systems. CMCS Director Dan Brillman struck a more optimistic tone, emphasizing value-based outcomes, streamlined quality measures, and a preference for partnership over regulation.

By the Numbers:

• ~10,000 NJ legal immigrants lost coverage in October 2026; 25,000 more under review
• Up to 300,000 Illinois residents projected to lose coverage
• Illinois faces up to a $51B funding loss over the next decade
• Tennessee's TennCare III generated $1.3B in shared savings in its first four years
• Medicaid managed care generates ~$45B annually in administrative overhead

Why it matters: H.R. 1 is reshaping Medicaid at a massive scale — threatening coverage for millions of vulnerable Americans while putting enormous fiscal and operational pressure on states already stretched thin.