What Medicaid Leaders Think About H.R. 1: Themes Across Three AHIP Panels

Over two days at AHIP, three separate sessions converged on a consistent picture: H.R. 1 is landing on systems already under pressure. The January 1, 2027 deadline is real but implementation will be iterative for years, and the moment demands more from plans than any prior redetermination cycle. The panels were:

• Implementing Medicaid Community Engagement Requirements — Andrea Maresca (Health Management Associates), Kinda Serafi (Manatt), Brendan Harris (UPMC Health Plan), Leah Chan (Georgia Budget and Policy Institute), moderated by Mikal Sutton (AHIP)
• Medicaid in Motion: Perspectives on the Road Ahead — Darin Gordon (former TennCare Director, Speire Healthcare Strategies), Matt Salo (founding NAMD Executive Director, Salo Health Strategies), Kate McEvoy (NAMD), Shannon McMahon (Kaiser Permanente)
• Current Issues in Medicaid: Insights from State Medicaid Directors — Amir Bassiri (New York Medicaid Director), Ann Jensen (Nevada Medicaid Director), Kate McEvoy

1. The compressed implementation timeline is a central challenge

Andrea Maresca set the frame clearly: CMS must issue interim guidance by June 1, states are expected to be operational by January 1. The traditional sequence of policy → IT → testing, which often takes years, is being compressed into a short window.

"If policy memos are not finalized and signed off on by mid-year, it's gonna be really tricky to be ready by January 1st. You need to really have user testing on some of those core elements by midyear — and if that's not happening, you need to be thinking about what are the backup plans." — Maresca

Brendan Harris added historical grounding: when his team implemented the ACA's MAGI eligibility requirements, it took a minimum of 18 months - and that was a known, well-resourced effort. Kinda Serafi was direct about what January 1 will actually look like: "It's gonna be bare bones on day one. This is not a 'let's get ready and maybe first quarter of next year we'll be done.' It's going to evolve over many months after January and in the coming years."

Matt Salo went further, predicting a "soft opening" — the policy goes into effect, but enforcement and disenrollment mechanics slow-roll as systems catch up. "The bad news stories that will come from people losing coverage because the systems weren't in place, because member outreach wasn't as effective as possible — that is a very, very bad message, and I don't think there's a state in this country who wants to see that, and I don't think the administration wants to see that either." Kate McEvoy pushed back, noting that CMS has given no signal of a soft rollout and that collaborative state-CMS work on minimum viable product functionality is more advanced than most people realize.

Nebraska's May 1 implementation — flagged by Harris — will be an early test. Georgia is the only multi-year data point anyone has. Both are being watched closely.

2. Data is the hardest technical problem - and there's no clean solution

States are statutorily required to first attempt to verify qualifying activities through available data but that data is incomplete, delayed, or cost-prohibitive. Serafi broke down the specific gaps:

• Quarterly wage data helps establish income-based exemptions but is delayed and doesn't capture hours worked
• The Work Number (Equifax) has hours data but is "extremely expensive" and "cost-prohibitive for many states"
• Gig economy data covers a slice of people but requires build time
• Medical frailty verification requires both a front-end screener and back-end claims verification via ICD-10/CPT codes - but MMIS data lags 12-15 months due to provider billing windows

McEvoy offered a more optimistic counterpoint from the state side: ex parte rates have improved from very low percentages to nearly 50% nationally, and CMS is actively piloting open-source, scalable tools to wrap around the adjudication process, including payroll-linked document uploads and interoperability with education databases. "We've really never seen that in history - CMS positioned to scale solutions toward reducing burden and creating more opportunity to build on routine eligibility."

Ann Jensen (Nevada) added that her state's IT modernization project (moving Medicaid eligibility and enrollment onto the exchange) predated H.R. 1 but now positions Nevada to frame Medicaid as one of multiple coverage options people can move between, which changes how compliance requirements get explained to members.

3. More people should be learning from Georgia

Leah Chan's sobering account from Georgia was the most concrete data across sessions. Georgia launched Pathways to Coverage in July 2023, an 1115 waiver offering Medicaid to adults up to 100% FPL who meet 80 hours/month of qualifying activities. Two and a half years in:

• As of January 2026: 15,000 Georgians actively enrolled — roughly 11% of those potentially eligible
• After two years: half of Georgia's counties had 25 or fewer residents ever enrolled; two counties had zero enrollees — in a state with the second-highest uninsured rate in the country
• 22% of application denials and 30% of disenrollments were procedural like missing forms
• Total spending after two years: $110 million, of which $52 million went to eligibility and enrollment system modifications - roughly $13,000 per enrollee

She also made clear that administrative costs did not front-load and go away: "I heard folks refer to the administrative cost as a startup cost, but that's not necessarily what we've seen. Costs have remained a consistent expense through the end of the first two years and beyond."

Darin Gordon echoed the Georgia lesson more broadly: "I wish more people would spend time with Georgia talking about some of the lessons they've learned so that we can avoid some of those missteps going forward."

4. Plans have a bigger role to play in supporting members and states with redetermination

Brendan Harris was candid about the risk-mix problem: H.R. 1 will likely remove healthier, working members who fail to document compliance while retaining the sicker, more complex population. "A lot of the healthy working people who don't have an exemption are going to go. We saw this in 2024 and had significant losses across the industry because states did not adequately account for that change in the mix."

This lands on top of already-stressed plan finances, provider tax changes, reductions in state-directed payments, and tight state budgets.

Amir Bassiri (New York) illustrated what this looks like from inside a state: New York had to terminate its 1332 waiver this week, moving approximately 400,000 people from the Essential Plan to the marketplace - though 1.3 million will remain in the Essential Plan through 2028-29, staved off by trust fund resources. "We see very significant shortfalls in 2027 that are very concerning and we're trying to get in front of them."

Harris's affirmative argument for plans: they are well positioned to support states because they maintain contact throughout the year. UPMC is beginning to work with Pennsylvania to accelerate encounter data submissions and flag likely medical frailty exemptions before the state has to process them individually. "These folks have been with us for years. Take those ICD-10 codes, say these folks really should not be subject to this - do a blanket exemption - and then you're only dealing with a manageable subset."

Gordon was direct about the stakes for plans: "Right now people are wanting to know why this partnership matters. So make it matter." He pushed back against plans pausing vendor relationships in a moment when outside expertise may be the most valuable thing available.

5. Work requirements are not the only H.R. 1 implementation challenge - but there are bright spots thanks to the PHE Unwinding

Multiple panels acknowledged the shift from annual to semi-annual eligibility reviews creating a continuous, rolling administrative burden. Salo argued the six-month renewal will ultimately be "just as important, just as impactful" as work requirements. Harris called it the "Unwinding on steroids." Gordon flagged the capitation rate risk specifically: "Six-month eligibility and those who are exempt from work engagement will cause some risk and disruption to rates. That needs to be front of line for states."

That administrative pressure isn't entirely without precedent - the PHE Unwinding, for all its chaos, forced states and plans to build outreach muscle they didn't have before. One of the quieter wins from that period: clearing a regulatory path for something as basic as texting members about their coverage - and that fight, it turns out, was anything but simple.

As Shannon McMahon explained: "All of us can get a text this morning from some retail organization telling us not to miss the sale. It has been a journey for Medicaid plans to simply be able to text people to make sure they keep their health insurance."

That journey actually involved coordination between CMS and the Federal Communications Commission (FCC). In 2024, existing Telephone Consumer Protection Act (TCPA) rules made it legally risky for plans and states to send unsolicited texts to Medicaid members, even for the purpose of keeping them enrolled. Getting permission-based texting infrastructure in place required CMS and the FCC to carve out a pathway that let plans reach members via SMS for eligibility and renewal purposes without running afoul of federal communications law. McMahon credited John Giles and his team specifically for doing the work of "locking arms with folks at the FCC and saying, this matters and here's why" - a quiet but consequential policy win that matters for successful H.R. 1 outreach.

6. The fraud, waste, and abuse conversation needs precision

The CRUSH initiative and the administration's focus on FWA dominated significant portions of the Medicaid in Motion panel. McEvoy was unequivocal that NAMD's membership shares the urgency - but drew a sharp distinction between fraud (bad actors requiring cross-state data analytics and enforcement) and waste (suboptimal spending that deserves different tools, not conflation with intentional misconduct).

The three areas she identified as genuine waste reduction opportunities: prescription drug spending (where most favored nation pricing and cell/gene therapy cost structures are legitimate targets), eligibility system costs (where CMS's open-source scaling approach creates real savings potential), and long-term care rebalancing toward home and community-based settings.

Salo pushed back on the political framing more directly: "When you see things like inefficiency or waste or even different public policy choices being lumped in with fraud and putting a big dollar target on it — we have to be careful that doesn't lead us to 'well, 20% of the whole system is fraud, so let's just take 20% off the top.'" His larger point was structural: Medicaid subsidizes Medicare to the tune of $240 billion annually, and having the nation's long-term care system entirely dependent on a means-tested low-income program is, in his words, "a really inhumane way of thinking about a fundamental core aspect of life."

Gordon went further, suggesting the entire financing formula deserves rethinking: "Let's revisit the formula. I would love to get to a point where we reward efficiency and better outcomes and get out of some of these other dynamics."

7. The moment requires leaders to look up

Several speakers pushed back against what Gordon called "energy leakage" - the tendency to spend more time processing how hard implementation will be than actually planning for it. "We can do hard things. If we spend less energy on that and instead hunker down and start thinking about the steps we can take, the end product will be better for us all."

McEvoy made the companion point for plans: the fire on the doorstep is real, but states need partners who are thinking 18-24 months out. "Most of the types of things you need to implement to see any kind of ROI aren't gonna happen in six months. Getting ahead of that makes the decisions you have to make then far less complicated."

She also flagged a political variable that often gets underweighted in operational planning: there are 20 new Medicaid directors in the last six months, and multiple states have gubernatorial elections this fall. The people plans are building relationships with today may not be in the same seats when January 1 arrives.

What panelists said could actually go right

The sessions closed on genuine optimism, not forced optimism:

• Better ex parte rates as states build out new income data infrastructure - a structural improvement that outlasts work requirements (Serafi)
• More formalized plan-state data exchange - the 834 bidirectional loop was optional during unwinding; this will make it necessary (Serafi)
• Deeper state-plan coalitions - Nevada's bimonthly task force meetings with plan presidents on program integrity topics are a model for the collaborative situational awareness that makes implementation manageable (Jensen)
• System modernization momentum - both Nevada and New York are mid-project on major eligibility modernization efforts that will outlast the current political moment and benefit consumers for years (Jensen, Bassiri)
• A larger CHW workforce embedded in rural communities (Chan)
• Broader coalitions at the state level - Georgia's struggles have generated more dialogue between state agencies, MCOs, advocacy partners, and policymakers than existed before (Chan)

Salo's closing reframe was worth noting: the debates that didn't happen - no ACA repeal, no block grant, no per capita cap - are themselves evidence of how embedded Medicaid has become in American life. "When people said 'we didn't elect you to undermine our Medicaid program' - that's a great thing to be positive about."

The practical standard heading into 2027, as Brendan Harris framed it: "Do you let the perfect get in the way of the good? Or do you try to get this thing launched knowing you're gonna have continuous improvements?" The room's answer was consistent across all three panels - launch, document, iterate, and build the partnerships now that will matter most when the systems catch up.

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