Health program leaders reveal insufficient Medicaid challenges, expected risks and solutions

After President Trump signed HR1 into law in July, Medzed specializes in health insurers’ efforts to find the most difficult Medicaid members to reach the highest cost, wondering how to best help customers in a new environment.

With that in mind, we participate in a group of leaders in hosted health programs that represent urban, rural and underserved communities in California and Maryland to understand how Medicaid changes will unfold on the frontline, if actions lag and solutions to mitigate potential declines. We promised to investigate participants anonymous in exchange for candidness, and they told us their truth–unchanged.

Five threats rarely talk about

Although some expected consequences regarding Medicaid changes, including coverage, member loss and unpaid care, our interviews identified five under-radar threats that could shake the Medicaid system and threaten health plans over the next two years:

1. Mathematical Problems in Quality Classification – Despite millions of dollars spent on outreach, their goals for HEDIS (Healthcare Effectiveness Data and Information Sets) were penalized. This is a common problem, which can suffer monetary fines and may worsen under the new regulations.

“We spent millions of people trying to get involved in those who were not involved, and we had little to gain.

2. Redefined “double hit” – Not only does the six-month qualification cycle trigger immediate coverage losses, but they are more costly when members return to the patient and the care plan is reset.

“Whenever someone falls and comes back, their care is interrupted and the expenses go up.”

3. Financial impact spreads rapidly – Revenue shrinking revenues expel hospitals, doctors and health centers from the network, cutting access overnight.

“If we can’t lower the interest rate, the provider will go away – members will lose access overnight.”

4. Authorization often exceeds members – Some states require expensive new programs (e.g., the universal social determinant of health screening), even if many members may churn and get out of the system within a few months.

“We were asked to establish a system requirement to limit the number of members’ enrollment to weeks.”

5. Trust is a hidden care currency – Repeated display Long-term outcomes depend on relationships, not only covering benefits, but new changes in Medicaid ignore this.

“People do things for people and organizations they trust. If they don't trust you, they won't do what you ask.”

Top five questions

In each of our conversations, respondents highlighted threats under these five radars by describing at least one of the following expected questions as a barrier to the operation of their respective programs and their ability to function effectively and effectively:

1. Re-qualification and management of overload – Survey participants are expected to move to a six-month redetermination cycle to undermine member coverage and overwhelming administrative system.

“We have lost over 50,000 members during Covid after the break…many people have not responded to emails or phone calls at all…we are preparing to make the situation worse.”

2. Loss of coverage for undocumented and expanded populations – The program predicts a drop in enrollment rates for undocumented individuals and ACA expansion teams, with a ripple effect on funding and nursing continuity.

“Of course, our first blow was losing the undocumented health plan.”

3. Increase unpaid care and provider strain. As members decline, more care returns, putting pressure on providers and reducing financial stability.

“We will have to provide care for uninsured people and then provide care for Bill, which isn’t going to be beautiful.”

4. Job requirements without labor infrastructure – Leaders fear members are disqualified for not complying with regulations – despite active care or lack of access to education, broadband or jobs.

“Where is all this work? What is the process? No labor development.”

5. Nursing and results reduction – Frequent loss of qualifications and restoration can interrupt the care plan, deteriorate conditions and increase downstream costs.

“When their situation worsens, they'll come back. It's hard to coordinate this way.”

Five strategies for solutions

The interview highlighted the urgent need for people-centered policies that balance cost containment with continuity, access and trust. We understand that the program is responding with a range of positive strategies, including internal planning, employee training, infrastructure adaptation and promotion to members. Several participants also mentioned participating in board and state advocacy. Their solutions are divided into five categories:

1. Keep people covered and reduce churn

• Active admission help: Send re-determination list 45-60 days in advance; employee/ECM-CS partners assist with renewal through text, email, letter and face-to-face help (iPad/kiosks).
• Onboarding and Accountability: Oriented and timely first PCP access is required at admission; consider small emergency rooms with bed-sensitive conditions to encourage access to PCP/urgent care.
• Coverage safeguards: Coordinate with states on clear work requirements processes and immigration policies to avoid fraud in protecting visits.

2. Expand access and capacity for member residence

• Extended hours and staffing for two shifts (e.g., 7–3 and 2–8) Thus, work members can participate without losing wages.
• Transport and dental capability: Expand cycling support and target dental network growth to address the ongoing desert.
• Provider network stability: Provide recruitment incentives and businesses; protect cash flow/reserves to maintain rates and prevent providers from exiting.

3. Update operations and data flows

• Management simplification: Standardize prior authorization and billing across plans; rules that consistently reduce provider friction.
• Interoperability: Design overlapping systems so the plan/provider can see where members receive care in real time to maintain continuity.

4. Establish payment and financial flexibility

• On-site payment and target pricing supervision Curb high-cost hospital environment without compromising access.
• Dual Qualification Special Needs Program Ready (D-SNP): Prepare for years of branches, serial recruitment and reserve reserves.

5. Prevention advocates, social determinants of health and trust

• Rebalancing prevention expenditures: Using proven health-related social needs (HRSN) tools, its classification workflow matches realistic recommendation capabilities.
• Community Partnership Use warm handover, so members actually use the service.
• Trust the front line: Invest in Community Health Navigator (CHN)/onsite teams and training; relationship-based participation as the core outcome driver.

Bottom line

The imminent changes in Medicaid will place health plans directly on rocks and hard places. Many hope that losing members due to new eligibility rules (job requirements, undocumented exclusion and population reduction) will accelerate the stirring. result? Plans expect revenue to decrease, just as care disruptions increase costs and quality fines.

These issues are not abstract policy debates – they are already formed operational and financial shocks. Health plans are preparing for change, but, from where I sit, there is no smarter guardrail, I believe the pressure will be cascading – members will lose coverage, providers will lose stability, and local economy will lose leaders in hosting health plans. Without thoughtful implementation, the new rules can create challenges across healthcare services, and consumers, consumers, consumers and local economies, and challenges. HR1 is not only a change in health policy; it has financial and operational impacts that markets, communities and policy makers need to carefully navigate.

Photo: Marchmeena29, Getty Images

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