State-Level Impacts of OBBBA Provisions: A Data Dashboard 

Visit the OBBBA Medicaid and Rural Health Transformation Data Dashboard – created by Milbank with data from RAND Health – to compare how OBBBA is projected to impact Medicaid funds by state.

The One Big Beautiful Bill Act (OBBBA), or HR1, signed into law last summer, made significant changes to the Medicaid program, such as adding work requirements and more frequent redeterminations for Medicaid expansion-enrolled adults. It also created the Rural Health Transformation Program (RHTP), a grant program for states to improve rural health care delivery. Although RHTP funds cannot be used for insurance coverage, they were envisioned as a way to partially offset federal Medicaid funding losses to states by paying for rural health care infrastructure and are included in many states’ Medicaid budgets. As such, the RAND analysis presents RHTP funds as an offset in Medicaid fund reduction.

The impact on Medicaid funds over the next decade will vary significantly by state. Using estimates from RAND Health, our new Data Dashboard shows at a high level how state Medicaid funds will be affected. The dashboard shows the percentage change in total Medicaid funds, net of RHTP investment, for each state from 2025 to 2034. This percentage change, presented on an interactive map, includes both funds received from the federal government and the state general fund.

Forty-four states are projected to experience a negativechange to their Medicaid (plus RHTP) funding, with six states expected to see a positive change. While Arizona will lose nearly 19% of its Medicaid funds, Wyoming will see nearly 10% more. States like Wyoming and Florida will experience an increase in their total Medicaid funding as they receive new money from the RHTP. The median state is projected to experience a -5.2% change in their total Medicaid fund between 2025 and 2034 (including both federal and state sources of funding).

How to Use the Dashboard

In addition to making interstate comparisons, policymakers can use the dashboard to see the relative impact of different OBBBA provisions within their own state. The provisions include the work requirements, bans or caps on provider taxes, caps on state directed payments (SDPs) for hospital and other health care services, more frequent Medicaid redetermination, and the RHTP.Policymakers can use this information to help set policy priorities. For example, states like New York and New Mexico have a relatively large expansion population of Medicaid enrollees who will be subject to new work requirements. These states may want to focus on measures to reduce the administrative burden of these new work requirements, thereby preventing unnecessary disenrollment from Medicaid. However, states like Tennessee, which does not have any expansion enrollees, will feel no impact to its Medicaid fund due to work requirements and will likely focus efforts on minimizing the impact of the law’s changes to SDPs. California, meanwhile, is projected to be most affected by the change in provider taxes and may choose to prioritize its response to that provision.

Methodology of Study

This dashboard was created using data from a 2026 study by RAND Health, which calculated the state-level impacts of key Medicaid provisions in the OBBBA.

It is important to note that the RAND study relied on several assumptions related to state responses to the OBBBA provisions, expected population growth, and expected health care spending. According to the RAND authors, the results should be interpreted as expected outcomes provided these assumptions hold. However, if state behavior varies from the assumptions for any given state, estimates may not be applicable for that state.

Two key assumptions are related to state Medicaid enrollment and the Medicaid budget gap. There are two kinds of provisions in OBBBA. The first reduces Medicaid spending by reducing enrollment. These provisions, such as work requirements, are anticipated to reduce the number of enrollees on Medicaid, thereby reducing the amount of money a state government will spend on its Medicaid program.[1] However, with effective implementation and enrollee compliance with work requirement reporting, states can mitigate disenrollment and the subsequent reduction to their Medicaid budgets. Even after OBBBA, expansion enrollees are funded by a 90% federal match, meaning that for every expansion enrollee kept on the Medicaid program, the federal government covers 90% of costs while the state contributes 10%.

The second kind of provision reduces federal funding for Medicaid without shrinking the Medicaid program. States must either find new funding sources to bridge the gap or lower Medicaid spending by limiting eligibility, covered services, provider payment rates, or some combination of those. For these provisions, the analysis follows the Congressional Budget Office in assuming that states make up one-half of the budget deficit by reducing Medicaid spending and the other half by leveraging the general fund. However, states responses may vary. States may choose to bridge the gap entirely with state funds, or entirely by reducing Medicaid spending, or anything in between. Should state behavior deviate from the assumptions in the report, the projected impact to Medicaid funds, both in total and from the state general fund, may differ from the estimates presented in the dashboard.

Conclusion

In the years ahead, state health systems will need to respond to all the changes brought forth by OBBBA, including how those changes are implemented, how services are funded, who they cover, and how health care access is maintained. The impact of the OBBBA is not limited to its budgetary implications. While some provisions, like work requirements, affect enrollment directly, other provisions, such as provider taxes, are anticipated to have an indirect impact on enrollment as well. With shrinking Medicaid federal funding flowing to states, some states may respond by reducing Medicaid enrollment to balance the budget, resulting in an estimated 7.6 million fewer Medicaid enrollees in 2034 than in 2025. The fiscal and coverage impacts of OBBBA will vary significantly by state, and how states respond will have significant implications on state budgets, health care financing and access to care.