Amid H.R.1 Rollout, States Implement Medicaid Work Requirements

Today’s issue explores how Supreme Court actions are shaping access to medication abortion, Medicaid work requirement policies under H.R.1, efforts to sustain rural hospital financing, and more.

In this edition of AcademyHealth’s Situation Report, we examine the implications of recent actions by the Supreme Court on access to medication abortion, including the temporary restoration of mifepristone by mail and the broader impact on reproductive health care delivery. We also explore shifting dynamics in federal health leadership following changes to the U.S. surgeon general nomination, highlighting the role of clinical credibility and political considerations in shaping public health priorities. Additional developments include evolving state strategies to comply with Medicaid work requirements amid ongoing uncertainty around the implementation of H.R.1

In today’s issue:

· How Some States Plan to Enforce Strict Medicaid Work Requirements

· Supreme Court Restores Access to Abortion Pill

· Senate Introduces Extension to Cost-Based Payments for Rural Hospitals

· Trump Replaces Surgeon General Nominee Amid Senate Concerns

How Some States Plan to Enforce Strict Medicaid Work Requirements

As the implementation of the 2025 reconciliation law (H.R. 1) continues to roll out, several states are choosing to adopt less restrictive policies to be in compliance with the new Medicaid work requirements. Adults (19-64) enrolled in the Affordable Care Act (ACA) Medicaid expansion program, and the partial Medicaid expansion waiver programs will be required to complete 80 hours of work, education, or community service monthly to maintain eligibility.

A total of 43 states, including DC that have adopted Medicaid expansion and Georgia and Wisconsin who have implemented partial Medicaid expansion waivers will be required to comply with the work requirements. States have until January 1, 2027 to implement the work requirements; however, seven states plan to comply with the ruling before the deadline or are planning to have more restrictive compliance policies. In July 2026, Arkansas is planning to do a soft launch of the implementation, without unenrolling anyone from the program until January 2027.

States are planning to utilize several data sources to verify compliance with the work requirements (including school attendance and community service), and to keep track of exemptions for veterans and persons who have been released from incarceration. As the January 1, 2027 deadline progresses, states have noted a need for guidance from the Centers for Medicare & Medicaid Services (CMS) on how to define certain exemptions such as medical frailty, community service, operationalizing the caregiver exemption, and how to account for those enrolled in school half-time.

An estimated 20 million people (about 30 percent of the total Medicaid enrollment) were enrolled in Medicaid expansion programs. These millions of people represent nondisabled adults without children, most of whom are living with a chronic disease, whose income barely places them above the federal poverty line. As conservatives continue to argue that Medicaid was not designed to provide coverage for those enrolled in the expansion, research has consistently shown that coverage losses in this population are associated with reduced access to care and delayed treatment. As states continue to plan for the implementing the mandates of work requirements, there is an open question as to how states will respond as their residents were to lose Medicaid coverage under the ACA expansion.

H.R. 1 does not require states to report on how work requirements are implemented or why individuals lose coverage, creating a significant evidence gap at a time of major policy change. Without standardized reporting, it may be difficult to distinguish coverage losses driven by employment changes from those caused by administrative hurdles or procedural errors. As implementation accelerates, researchers will play a critical role in tracking state approaches, estimating eligibility‑based coverage loss, and assessing impacts on access, health outcomes, and administrative burden.

Supreme Court Restores Access to Abortion Pill

Early Monday morning, the Supreme Court issued an administrative stay to temporarily restore access to mifepristone by mail after receiving a series of emergency appeals. The series of appeals were triggered by Friday’s State of Louisiana’s lower court ruling, that eliminated telemedicine access to the pills nationally, even in states where abortion care is legal.

Mifeprex (brand name) was first approved by the Food and Drug Administration (FDA) in 2000 in combination with misoprostol, to terminate an intrauterine pregnancy through ten weeks gestation (or within 70 days of the patient’s last menstrual period). In 2019, the generic, Mifepristone Tablets, 200 mg (Mifepristone) was approved. Since 2021, mifepristone has been available by mail after the FDA permanently removed the in-person dispensing requirement.

Telemedicine access to medication abortion has allowed over 8,000 patients per month in 2023 to access mifepristone in the U.S. In 2025, about 91,000 patients in states with total abortion bans were able to access this medication for their reproductive health through Shield Laws, which protect abortion providers and patients from out-of-state legal threats. Blocking access to mifepristone by mail would disrupt safe, reproductive health care access to thousands of patients.

Senate Introduces Extension to Cost-Based Payments for Rural Hospitals

Bipartisan legislation introduced this week would extend the Rural Community Hospital Demonstration for an additional five years, preserving a cost‑based Medicare payment model for certain rural hospitals that are too large to qualify as Critical Access Hospitals but remain financially vulnerable. The program, capped at 30 participating hospitals at a time, allows eligible rural facilities with fewer than 51 beds and 24‑hour emergency services to receive cost‑based reimbursement for inpatient care rather than standard Medicare rates. It is currently set to expire in June 2028.

CMS’s most recent evaluation found that participating hospitals received significantly higher Medicare payments, between $1.6 million and $2.7 million more per year than they would have under standard payment rules, and hospital leaders reported the additional funding was critical to maintaining financial stability. Even so, CMS noted that margins for many participating hospitals still did not reach break‑even levels, underscoring ongoing financial pressure in rural health systems. Supporters of the extension argue the model helps hospitals remain open, retain staff, and preserve access to inpatient and emergency care in communities where alternatives are limited.

As rural hospitals continue to face low patient volumes, workforce shortages, and challenging payer mixes, the demonstration offers an opportunity to evaluate how alternative payment models affect financial viability, service availability, and patient access in rural settings. Researchers can help assess whether cost‑based reimbursement improves long‑term stability, how it compares to other rural support mechanisms, and what tradeoffs exist for Medicare spending and care delivery.

Trump Replaces Surgeon General Nominee Amid Senate Concerns

The Trump administration has withdrawn its nomination of Casey Means for U.S. surgeon general and instead selected Nicole Saphier, a practicing physician and media contributor. The change follows concerns from Senate Republicans, including Bill Cassidy, about Means’ lack of clinical licensure, experience working with patients, and positions on vaccines. Saphier supports vaccination but has expressed skepticism of mandates.

The switch highlights ongoing challenges in securing Senate confirmation for health leadership roles and signals the importance of clinical credibility and positions on vaccination in the approval process.

Researchers can examine how leadership selection and political dynamics influence federal health priorities, public health messaging, and trust in institutions—particularly in areas like vaccination, prevention, and evidence-based policymaking.