H.R. 1, the budget reconciliation bill, makes deep cuts to Medicaid and Affordable Care Act (ACA) coverage that will harm Black pregnant and postpartum people who rely on Medicaid for essential care before, during, and after pregnancy. The Black Maternal Health Federal Policy Collective urges states to protect and extend coverage, improve infrastructure and support providers, and eliminate obstacles to ensure ongoing access to maternal health care.
Impact of H.R. 1 on Medicaid and the Affordable Care Act (ACA)
H.R. 1’s health care provisions overhaul Medicaid and the ACA and fundamentally reshape the U.S. health care system, increasing health care costs and making essential care unaffordable for Americans. These changes would restrict insurance eligibility, reduce covered services, and limit health care access for millions. The cuts would also force hospital closures, especially in rural or underserved areas, leaving people without critical care, worsening health disparities, and leading to poorer health outcomes.
Imposed Work Requirements on People Who Rely on Medicaid
Under H.R. 1, states will be required to impose work requirements upon Medicaid enrollees. These requirements have proven to be administrative barriers to access, and people—even those who meet the requirements but simply miss a filing deadline—are anticipated to lose coverage as a result. Despite work requirement exemptions for pregnancy, new eligibility verification burdens will lead to coverage loss, particularly for working mothers.
Changes to Medicaid Eligibility and Enrollment
States will be required to redetermine eligibility for Medicaid expansion-covered adults every six months, instead of annually. Additionally, the law has changed retroactive Medicaid coverage. States previously paid claims for services up to three months before an individual submitted an application. Starting in 2027, retroactive Medicaid coverage will be reduced to one month. Both enrollment changes will create barriers and impose additional financial burdens on people who rely on Medicaid for health care. Lastly, some immigrants, including Deferred Action for Childhood Arrivals (DACA) recipients, people with Temporary Protected Status (TPS), and refugees, will also lose eligibility for Medicaid coverage.
Changes to Medicaid Funding for Providers
Medicaid enrollees are also barred from using their insurance to access care at facilities run by certain reproductive health providers, namely Planned Parenthood, limiting access to abortion care, contraception, sexually transmitted infection (STI) testing, cancer screenings, and other essential services.
Rollbacks to the ACA
ACA marketplace coverage has provided affordable coverage to millions of women before and after pregnancy. In 2023, more than one-third of Black people with marketplace coverage received financial assistance to purchase insurance. Under H.R. 1, the ACA’s enhanced tax premium credits will not be extended past their expiration date of December 31, 2025. As a result, beginning in January 2026, average out-of-pocket insurance premiums are expected to double and financial assistance will be drastically reduced for millions. An estimated 4.8 million ACA marketplace enrollees are expected to lose their health coverage following these changes.
Changes to ACA Eligibility and Enrollment
Similar to Medicaid eligibility changes, some immigrants, including Deferred Action for Childhood Arrivals (DACA) recipients, people with Temporary Protected Status (TPS), and refugees, will also lose eligibility for ACA marketplace plans. For those seeking to enroll in Medicaid during special enrollment periods, additional verification processes will be added, while automatic enrollment will be eliminated for subsidy-eligible individuals. These changes will disproportionately impact low-income families and contribute to higher uninsured rates.
Consequences of Funding Cuts for Black Maternal Health
The Congressional Budget Office (CBO) estimates that 1.3 million people will lose coverage and become uninsured by 2026; this number will jump to 5.2 million people in 2027, 6.8 million in 2028, 8.6 million in 2029, and then grow to 10 million people uninsured by 2034 due to Medicaid funding cuts under H.R. 1. An additional 4.1 million are projected to lose ACA coverage due to reduced premium tax credits and rule changes. For all people, but especially for Black women, higher uninsured rates would mean reduced access to care before, during, and after pregnancy—care that is critical for managing chronic conditions that often drive life-threatening pregnancy complications.
Disruptions in Postpartum Care from Medicaid Coverage Loss
Coverage loss will disrupt postpartum care, a time when complications can still arise. This can force patients to seek emergency care, leading to delays and missed diagnoses, creating a greater risk for Black women in particular, who are already at greater risk of dying from pregnancy-related causes, experiencing severe maternal morbidities, and having negative birth outcomes. The loss of life-saving postpartum care would further exacerbate these risks.
Maternal Health Benefits In Jeopardy
Medicaid funding cuts will transfer financial burdens to states, forcing them to tighten their budgets. Budget restraints could lead states to roll back (or not offer) optional maternal health benefits such as Medicaid coverage for up to one year postpartum, midwifery care, and birth doula support—all of which have been shown to improve maternal health outcomes.
Worsening Access to Maternity Care
Funding cuts would put rural hospitals, community clinics, and reproductive health providers at risk of closure or service cutbacks, creating and worsening maternity care deserts and leaving Black pregnant and postpartum people with fewer options for preventive and emergency care.
Recommended State Actions to Protect Maternal Health Care Access
In response to H.R. 1, state lawmakers will have to make critical policy decisions. These decisions will undoubtedly require deep consideration of constituent health care needs and state budgets. Below are recommendations that can mitigate harm from H.R. 1’s federal funding cuts and protect maternal health care access.
Defend and Expand Coverage
- Despite the elimination of federal funding for essential health services, states should retain those options because they are proven to support positive health outcomes, saving states money in the long-term. States should maintain Medicaid-covered maternal health services in their budgets using state-only funds, including postpartum coverage for one year as well as birth doulas and midwifery care. States that have not extended Medicaid postpartum coverage should extend it to ensure birthing people have access to critical services.
- State Medicaid agencies should propose Medicaid State Plan Amendments (SPAs) that expand access to family planning services, including contraceptives, STI screenings, and Pap smears. Currently, eighteen states have secured and implemented SPAs, successfully broadening access to care for individuals who would not otherwise qualify for Medicaid. In tandem, state policymakers should provide supplemental funding for family planning providers to ensure continued access to reproductive health care for low-income individuals. Access to reproductive health care facilitates healthy birth spacing and increases the likelihood of early and consistent prenatal care, which is critical for individuals who decide to become pregnant.
Strengthen Health Care Infrastructure
- State policymakers should strengthen local providers’ ability to provide care and health care infrastructure by directing state funds to safety-net hospitals, rural clinics, and reproductive health providers. For example, the California state legislature recently passed a bill that would help sustain labor and delivery units in rural hospitals, while a Texas resident physician grant program incentivizes medical school graduates to practice in underserved areas.
- State policymakers should provide state funding to hospitals that will lose Emergency Medicaid funding to help fill the federal funding gap.
- State Medicaid agencies, health departments, and social service agencies should coordinate and protect Medicaid perinatal care coordination programs that connect mothers with health and social services. These programs have been shown to reduce rates of low birthweight, preterm births, and infant mortality.
Address Barriers to Medicaid Enrollment
- States should resist the impulse to submit Section 1115 waivers that would permit them to impose work requirements before the federal law mandates these requirements to be imposed in 2027. Work requirements have been shown to lead to coverage loss, even for working mothers.
- States should limit Medicaid enrollment verifications to make it easier for people in need to enroll. State Medicaid programs should permit self-attestation for eligibility where federally allowed. Given that H.R. 1 imposes new enrollment requirements that would restrict participation in the program, it is critical to ensure existing enrollment standards do not present unnecessary hurdles.
Keep the General Public Informed of Health Coverage Options
- State policymakers and agencies must provide clear, timely, and frequent information to the general public, Medicaid beneficiaries, and people enrolled in ACA marketplace plans regarding upcoming enrollment and eligibility changes. Given rapid changes, it is critical that the public be informed of health care coverage options. States should also have specific outreach and enrollment efforts in Black communities, immigrant communities, and in rural areas to ensure people understand what coverage options are available.
Conclusion
To truly address the potential hardships resulting from H.R. 1’s federal funding cuts to Medicaid and the ACA, states must adopt creative and innovative strategies to serve their populations. States must ensure continued health care access for their constituents, who will be vulnerable to rising health care costs, reduced coverage of health care services, and limited access to essential care before, during, and after pregnancy.
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Tags: Black Mothers, black maternal health, health equity, health care cuts, reproductive health
State Actions to Protect Black Maternal Health
H.R. 1, the budget reconciliation bill, makes deep cuts to Medicaid and Affordable Care Act (ACA) coverage that will harm Black pregnant and postpartum people who rely on Medicaid for essential care before, during, and after pregnancy. The Black Maternal Health Federal Policy Collective urges states to protect and extend coverage, improve infrastructure and support providers, and eliminate obstacles to ensure ongoing access to maternal health care.
Impact of H.R. 1 on Medicaid and the Affordable Care Act (ACA)
H.R. 1’s health care provisions overhaul Medicaid and the ACA and fundamentally reshape the U.S. health care system, increasing health care costs and making essential care unaffordable for Americans. These changes would restrict insurance eligibility, reduce covered services, and limit health care access for millions. The cuts would also force hospital closures, especially in rural or underserved areas, leaving people without critical care, worsening health disparities, and leading to poorer health outcomes.
Imposed Work Requirements on People Who Rely on Medicaid
Under H.R. 1, states will be required to impose work requirements upon Medicaid enrollees. These requirements have proven to be administrative barriers to access, and people—even those who meet the requirements but simply miss a filing deadline—are anticipated to lose coverage as a result. Despite work requirement exemptions for pregnancy, new eligibility verification burdens will lead to coverage loss, particularly for working mothers.
Changes to Medicaid Eligibility and Enrollment
States will be required to redetermine eligibility for Medicaid expansion-covered adults every six months, instead of annually. Additionally, the law has changed retroactive Medicaid coverage. States previously paid claims for services up to three months before an individual submitted an application. Starting in 2027, retroactive Medicaid coverage will be reduced to one month. Both enrollment changes will create barriers and impose additional financial burdens on people who rely on Medicaid for health care. Lastly, some immigrants, including Deferred Action for Childhood Arrivals (DACA) recipients, people with Temporary Protected Status (TPS), and refugees, will also lose eligibility for Medicaid coverage.
Changes to Medicaid Funding for Providers
Medicaid enrollees are also barred from using their insurance to access care at facilities run by certain reproductive health providers, namely Planned Parenthood, limiting access to abortion care, contraception, sexually transmitted infection (STI) testing, cancer screenings, and other essential services.
Rollbacks to the ACA
ACA marketplace coverage has provided affordable coverage to millions of women before and after pregnancy. In 2023, more than one-third of Black people with marketplace coverage received financial assistance to purchase insurance. Under H.R. 1, the ACA’s enhanced tax premium credits will not be extended past their expiration date of December 31, 2025. As a result, beginning in January 2026, average out-of-pocket insurance premiums are expected to double and financial assistance will be drastically reduced for millions. An estimated 4.8 million ACA marketplace enrollees are expected to lose their health coverage following these changes.
Changes to ACA Eligibility and Enrollment
Similar to Medicaid eligibility changes, some immigrants, including Deferred Action for Childhood Arrivals (DACA) recipients, people with Temporary Protected Status (TPS), and refugees, will also lose eligibility for ACA marketplace plans. For those seeking to enroll in Medicaid during special enrollment periods, additional verification processes will be added, while automatic enrollment will be eliminated for subsidy-eligible individuals. These changes will disproportionately impact low-income families and contribute to higher uninsured rates.
Consequences of Funding Cuts for Black Maternal Health
The Congressional Budget Office (CBO) estimates that 1.3 million people will lose coverage and become uninsured by 2026; this number will jump to 5.2 million people in 2027, 6.8 million in 2028, 8.6 million in 2029, and then grow to 10 million people uninsured by 2034 due to Medicaid funding cuts under H.R. 1. An additional 4.1 million are projected to lose ACA coverage due to reduced premium tax credits and rule changes. For all people, but especially for Black women, higher uninsured rates would mean reduced access to care before, during, and after pregnancy—care that is critical for managing chronic conditions that often drive life-threatening pregnancy complications.
Disruptions in Postpartum Care from Medicaid Coverage Loss
Coverage loss will disrupt postpartum care, a time when complications can still arise. This can force patients to seek emergency care, leading to delays and missed diagnoses, creating a greater risk for Black women in particular, who are already at greater risk of dying from pregnancy-related causes, experiencing severe maternal morbidities, and having negative birth outcomes. The loss of life-saving postpartum care would further exacerbate these risks.
Maternal Health Benefits In Jeopardy
Medicaid funding cuts will transfer financial burdens to states, forcing them to tighten their budgets. Budget restraints could lead states to roll back (or not offer) optional maternal health benefits such as Medicaid coverage for up to one year postpartum, midwifery care, and birth doula support—all of which have been shown to improve maternal health outcomes.
Worsening Access to Maternity Care
Funding cuts would put rural hospitals, community clinics, and reproductive health providers at risk of closure or service cutbacks, creating and worsening maternity care deserts and leaving Black pregnant and postpartum people with fewer options for preventive and emergency care.
Recommended State Actions to Protect Maternal Health Care Access
In response to H.R. 1, state lawmakers will have to make critical policy decisions. These decisions will undoubtedly require deep consideration of constituent health care needs and state budgets. Below are recommendations that can mitigate harm from H.R. 1’s federal funding cuts and protect maternal health care access.
Defend and Expand Coverage
Strengthen Health Care Infrastructure
Address Barriers to Medicaid Enrollment
Keep the General Public Informed of Health Coverage Options
Conclusion
To truly address the potential hardships resulting from H.R. 1’s federal funding cuts to Medicaid and the ACA, states must adopt creative and innovative strategies to serve their populations. States must ensure continued health care access for their constituents, who will be vulnerable to rising health care costs, reduced coverage of health care services, and limited access to essential care before, during, and after pregnancy.
Download the PDF version →
Other Resources:
Tags: Black Mothers, black maternal health, health equity, health care cuts, reproductive health