The federal budget reconciliation bill (H.R. 1) passed by Congress in July 2025 included the largest overhaul of the Medicaid program since 2010. Despite the new law’s profound impacts in many key areas of Medicaid—reshaping who can enroll and stay covered, adding work reporting requirements and more frequent eligibility checks, restricting eligibility for non-citizens, and changing the ways that states can finance their programs—there is currently no federal guidance in place directing states to monitor and oversee how these changes will impact their residents or state budgets.
To help address this gap, researchers at the University of Minnesota School of Public Health (SPH) State Health Access Data Assistance Center (SHADAC) developed an issue brief that outlines why states should invest in monitoring, lays out a step-by-step timeline for putting monitoring systems in place, and identifies priority areas states should track as the policy changes roll out.
“State leaders and federal budget analysts are already warning that these changes could lead to widespread coverage losses, strain state budgets, increase administrative burdens for families and agencies, and drive up uncompensated care for clinics and hospitals,” said Elizabeth Lukanen, director of SHADAC and co-author. “Given the pressure to implement these policies quickly, there’s a real risk that the urgency of rollout will crowd out careful monitoring. This brief is meant to help states stay focused on tracking the real-world impacts so they can identify problems early and protect access to care.”
To develop the issue brief, researchers reviewed the policy changes in H.R.1 and synthesized guidance from state officials, federal advisory groups, and past Medicaid implementation efforts. The issue brief is divided into three distinct priority areas that states should consider, and a timeline for adopting them:
- Immediate operational and coverage impacts. This first phase should include tracking initial enrollment changes, administrative costs, and early warning signs like call center backlogs and prescription disruptions.
- Enrollee experience and access to care. To be implemented early in the policy implementation phase, this priority includes suggestions on monitoring paperwork burdens, provider stability, and whether people can still get timely primary and specialty care.
- Long-term health and economic outcomes. This priority takes place post-implementation to gauge the downstream effects of the federal policy changes, and includes assessing effects on health outcomes, household financial strain, employment patterns, and overall insurance coverage in communities.
“Without strong monitoring in place, states risk flying blind as these major Medicaid changes roll out,” said SHADAC’s Emily Zylla, a co-author. “These policy changes may fall hardest on children, people with disabilities, non-citizens, people of color, and rural residents, so it’s critical that states collect and analyze data by geography, age, gender and sex, race and ethnicity, and disability status. Transparent, real-time data can help states spot unintended harms early, prevent disparities from widening, and adjust policies before small problems become large ones.”
The issue brief was supported by the Robert Wood Johnson Foundation’s State Health and Value Strategies (SHVS) program. As part of this initiative, SHADAC provides technical assistance, analysis, and evaluation support to state officials and agencies. The views expressed in the brief do not necessarily reflect the views of the Foundation.
