H.R. 1 drastically changed Medicaid eligibility, including for some immigrant populations and for other beneficiaries through strict work requirements. States must implement work requirements by December 31, 2026, and certain groups—caregivers, medically frail individuals, and those experiencing a short-term hardship, among others—may submit an exemption from the work requirements. While exemptions sound great in theory, eligibility restrictions like work requirements, even those with seemingly expansive exemptions, result in a loss of health care coverage. Changes such as the loss of eligibility for legal migrants (asylees, refugees, folks with temporary protected status, and survivors of domestic violence or trafficking seeking or granted lawful status), stringent work requirements, and biannual rather than annual eligibility redeterminations will fundamentally reshape access to care across the country.
Nearly 12 million people are expected to lose health coverage as a result of H.R. 1.
When people are denied coverage or coverage is reduced or terminated, the government must provide applicants or beneficiaries with due process. Compliance with due process is not optional, and when denials, reductions, or terminations of Medicaid benefits increase, so do the administrative burdens and costs on the government. With millions of people losing a public benefit (Medicaid), the government will be spending hundreds of millions of dollars just to explain and defend Medicaid denials, reductions, or terminations—money that would be better spent on delivering and improving critical care for vulnerable populations.
Due process requires providing notice and a hearing before denying, reducing, or terminating a public benefit.
The U.S. Constitution and federal law provide due process protections for Medicaid beneficiaries. Under the Fourteenth Amendment’s Due Process Clause, state governments must fairly and equitably follow procedural safeguards before denying a person of their protected interest in life, liberty, or property. Medicaid beneficiaries are statutorily entitled to the benefit and therefore have a protected property interest in their public health care benefit. There are two key components of constitutional procedural due process: reasonable notice and a fair hearing. First, the government must reasonably provide timely and adequate notice of the anticipated changes before denying, reducing, or terminating an individual’s benefits. Second, the government must provide beneficiaries with a meaningful opportunity to be heard.
“The opportunity to be heard must be tailored to the capacities and circumstances of those who are to be heard.”
What is required for sufficient notice and a fair hearing may depend on the nature of the benefit, the characteristics of the persons whose property interest is at issue, the harm likely to occur if the benefit is interrupted, and the administrative burden on the government. In Golberg v. Kelly, the Supreme Court held that the Due Process Clause requires states to provide notice and a hearing before reducing statutorily entitled to benefits. Notably for this discussion, the Court also concluded that the potential increase in administrative burdens—"increased costs” and worsening “burdensome caseloads”—is outweighed by the beneficiaries’ interest in uninterrupted public assistance, (in this case, the public benefit was financial aid that provided lower income New Yorkers with food, clothing, housing, and health care). Therefore, states and localities cannot evade due process in their implementation of H.R. 1. A person’s right to due process is more important than merely increased costs and high caseloads.
In Goldberg, the particulars of notice and hearing procedures needed to be tailored to the specific class of recipients—lower income folks. While a seven-day mailed notice of a change in benefits was constitutionally sufficient because it was reasonably likely to notify a recipient of anticipated changes, New York’s hearing procedures were not. The state’s hearing processes only allowed the opportunity to present evidence in writing, which was not constitutionally sufficient for this class of beneficiaries. Because this group of people generally “lack[ed] the educational attainment necessary to write effectively,” as well as the resources to “obtain professional assistance” in confronting the evidence against them, New York needed to provide beneficiaries with the ability to present information orally in addition to in writing.
These principles apply to the implementation of H.R. 1. While the benefit at issue in Golberg was financial assistance under the Aid to Families with Dependent Children, the Court’s holding has long been understood to apply the protected property interest held by Medicaid beneficiaries. Due process requires meeting people where they are, and governments are likely to face challenges providing constitutionally adequate due process to many people who will lose health coverage because of H.R. 1. This is especially true for the migrants stripped of their eligibility, many of whom may have limited English proficiency or a disability stemming from an experience related to their legal status (political violence, sexual violence, human trafficking, etc.).
The federal constitution provides a floor, not a ceiling, for due process protections.
- The federal government has gone beyond the requirements in Goldberg by codifying more detailed procedural due process requirements into federal law. For example, regulations promulgated by the Centers for Medicare and Medicaid Services (CMS) mandate states to maintain a hearing system that is accessible to persons with limited English proficiency and persons with disabilities, among other requirements.The bottom line: complying with due process requires a lot of time, money, and staff. The government must continue to comply with these regulations as it denies, reduces, or terminates access to care for millions of people pursuant to H.R. 1.
We have long known that implementing restrictions on Medicaid costs the government immense resources. Complying with due process requires hiring and training caseworkers and judges, processing paperwork and conducting outreach, and updating technology that can handle the increased administrative burdens. By terminating benefits for certain legal migrants, requiring proof of employment or a waiver, and determining eligibility twice as frequently, H.R. 1 will significantly increase these burdens on states and localities, costing our government hundreds of millions of dollars. Analyses shows that implementing work requirements in Ohio would cost about $378 million over five years for increased caseloads. In Pennsylvania, Medicaid work requirements would cost the state $600 million to hire 300 additional staff. Similar figures have come out of states including Kentucky, Michigan, Minnesota, Tennessee, and Virginia. States and the federal government generally split administrative costs, so taxpayers will be covering the cost of these burdens nationwide.
In fact, it costs more to implement eligibility restrictions than it does to provide health care. The Government Accountability Office (GAO), a nonpartisan agency monitoring federal programs and spending, highlighted that it costs Georgia twice as much to implement its Medicaid work requirement program than it does to provide health care. The GAO analysis found that, during fiscal year 2021 through the first quarter of 2025, the state had spent $54.2 million on administrative costs—complying with due process—and $26.1 million on health care. Rather than providing patients with health care, the state chose to restrict public benefits and divert essential funds from patients to administrative burdens.
H.R. 1 stands for the same proposition. Rather than spending money to expand or improve care, Congress chose to restrict care. H.R. 1 provides the Department of Health and Human Services with $200 million to provide to states for implementation ($100 million distributed equally among 50 states, and $100 million distributed based on Medicaid population size), but as demonstrated above, this is a drop in the bucket. A smaller state alone may require $100 million just for implementation, and not to mention ongoing costs amounting to tens of millions of dollars a year.
Due process is vital to protect the rights of Medicaid beneficiaries, but restrictive policies that greatly increase the under- or uninsured population—by way of denials, reductions, and terminations of coverage—divert essential resources away from patients and providers. We should aim to provide the safest, highest quality care in the most affordable and efficient way. H.R. 1 moves in the opposite direction, diverting hundreds of millions of dollars away from care and into bureaucratic processes designed to police eligibility restrictions. Policymakers should pursue reforms that efficiently expand access to care, not ones that make exclusion more expensive than treatment.