Primary Care Lens: What HR 1 Means for Medicaid and Primary Care

Welcome back to Primary Care Lens!

Jubril Oyeyemi, MD, chief medical officer of the Camden Coalition of Health Care Providers and founder of the Cherry Hill Free Clinic, sits down with Giridhar Mallya, MD, MSHP, senior policy officer at the Robert Wood Johnson Foundation, to break down HR 1, the sweeping 2025 federal law reshaping Medicaid, the Affordable Care Act, and SNAP. The conversation moves from statute to exam room, tracing how new Medicaid work requirements will land on primary care practices starting January 2027.

HR 1 Medicaid Work Requirements and Coverage Loss in Primary Care

Mallya frames HR 1's Medicaid provisions around a projected loss of coverage for roughly 7.5 million people, driven mainly by reduced federal funding and new work requirements for the Medicaid expansion population.¹ Adults, including some parents of teenagers, will need to document 80 hours a month of work, school, or volunteering to keep coverage starting in January 2027. Mallya points to Arkansas' earlier work-requirement rollout, where nearly 20,000 people lost coverage within six months, largely because eligible people could not navigate the exemption paperwork.

Editors’ note: Mallya notes that Medicaid work requirements will apply to parents with kids 16 or older. However, it is actually 14 or older.

Oyeyemi presses on what this means for solo practices and community clinics without care-navigation infrastructure. He notes paperwork burden is already a well-documented driver of clinician burnout, and these new requirements will layer additional documentation demands onto both patients and their care teams, often for patients managing serious chronic disease. Mallya suggests building support programs using nurses, community health workers, and trainees to help patients document eligibility and medical frailty exemptions before the January 2027 deadline, calling it a genuine opportunity to engage students and trainees in a concrete, patient-facing project.

The pair also discusses who falls into the Medicaid expansion population now facing these requirements. Mallya explains that prior to the Affordable Care Act, Medicaid eligibility in many states was limited to children, pregnant patients, and people with disabilities below strict income thresholds. The Affordable Care Act broadened eligibility to anyone earning up to 138% of the federal poverty level. It is this expansion population, largely working adults with modest incomes, who now face the new documentation requirements, with impact varying by state based on each state's baseline eligibility policies.

Medical Frailty Exemptions and the Documentation Burden for Clinicians

A year after HR 1's passage, the federal government narrowed its definition of medical frailty, the standard used to exempt sick patients from work requirements. For nearly a year, federal signals suggested a broad, flexible definition consistent with prior practice, covering conditions such as substance use disorders, recent cancer diagnoses, or multiple complex chronic conditions. The final rule, released roughly a month before this conversation, reversed course with a much narrower standard.

Mallya describes a patient recently diagnosed with lymphoma and undergoing chemotherapy who may not qualify as medically frail under the new rule, even while unable to work through treatment and its side effects. Clinicians documenting these exemptions face the same paperwork burden already cited as a driver of burnout, now applied to patients simultaneously managing serious illness.

The discussion turns to equity, with Mallya highlighting two populations facing outsized impact. Lawfully present immigrants, including refugees, asylees, and survivors of trafficking, lost Medicaid and SNAP eligibility under the same law, even though undocumented immigrants were never eligible for either program. Mallya notes the same legislation that cut roughly a trillion dollars from Medicaid also directed substantial new funding toward immigration detention and enforcement. He describes a chilling effect on mixed-status families, where a parent's immigration status can deter an entire household, including citizen children, from engaging with public programs.

Mallya also traces declining vaccine confidence to the loss of US measles elimination status for the first time in 25 years, attributing the resurgence to misinformation amplified at the highest levels of government. He outlines how the American Academy of Pediatrics has legally challenged the removal of 6 vaccines from the childhood schedule, a change made without new safety data and without going through the Advisory Committee on Immunization Practices, noting the challenge has so far paused some of the changes.

Oyeyemi closes by asking Mallya, a family physician turned policy officer, what advice he has for primary care clinicians drawn toward health policy work. Mallya encourages clinicians considering a similar path to pursue it, describing his own turning point as an intern in a Philadelphia ICU treating patients with preventable, low-cost conditions that had gone untreated for lack of coverage.

References

1. Congressional Budget Office. Information concerning Medicaid-related provisions in title IV of H.R. 1. Published June 24, 2025. Accessed August 5, 2026. https://www.cbo.gov/publication/61510

2. Center on Budget and Policy Priorities. By the numbers: harmful Republican megabill will take health coverage away from millions of people and raise families' costs. Published August 27, 2025. Accessed August 5, 2026. https://www.cbpp.org/research/health/by-the-numbers-harmful-republican-megabill-will-take-health-coverage-away-from