Connected RCM: Insights and Overviews

CONNECTED RCM · REGULATORY INTELLIGENCE BRIEF

Medicaid Dependency by State

Medicaid enrollment as a percentage of state population — FY 2024. States with the highest dependency face the greatest exposure to OBBBA work requirement enrollment losses.

SOURCE: CMS / MACPAC FY2024 % OF STATE POPULATION ENROLLED OBBBA CONTEXT · PUB. LAW 119-21

State

Enrollment %

Expansion

RCM Risk Note

Louisiana

43.5%

Highest dependency nationally. Work requirement disenrollment projected to be severe.

New Mexico

40%

RAND projects 20%+ enrollment reduction. High rural FQHC exposure.

West Virginia

39%

Among states most exposed to work requirement and redetermination impacts.

California

38%

Largest raw enrollment (12.7M). FQHC density high. Noncitizen eligibility changes add exposure.

Vermont

34%

Small population, high dependency rate. Budget impact from federal match reduction will be acute.

D.C.

34%

High urban poverty concentration. Work requirement compliance complex in dense metro settings.

Oregon

33%

RAND projects 20%+ enrollment reduction. Strong FQHC network at risk.

New York

33%

2nd largest raw enrollment. Provider tax changes will strain state financing substantially.

Hawaii

32%

Island geography limits alternatives for disenrolled patients. Access risk amplified.

Washington

32%

High enrollment, strong state infrastructure. Transition burden will still be significant.

RCM STRATEGIC IMPLICATION

States with enrollment rates above 30% face the most severe exposure to OBBBA-driven coverage disruption. For RCM teams, high Medicaid dependency translates directly into elevated denial risk from eligibility churn, increased sliding-scale volume, and administrative burden from semi-annual redetermination cycles beginning January 2027. The pattern is consistent: the states most dependent on Medicaid are also the states with the fewest coverage alternatives for disenrolled patients — amplifying both the access and revenue impact for safety-net providers.

CMS / MACPAC FY2024 Average Monthly Enrollment · USAFacts Medicaid Enrollment Analysis · RAND Health OBBBA Medicaid Impact Study · KFF State Health Facts · Pew Research Center Medicaid Data Analysis (Jan. 2025)