How H.R. 1 Medicaid Changes Could Increase Uncompensated Care for Hospitals and FQHCs in 2027

Coverage losses start showing up as unpaid encounters in 2027. Here is where the pressure lands for hospitals and health centers — and where some of that care can still be paid.

H.R. 1 is expected to raise uncompensated care because three of its Medicaid provisions start on January 1, 2027: six-month redeterminations, work requirements for expansion adults, and a retroactive coverage window cut from three months to one or two. The Congressional Budget Office projects 5.2 million more uninsured people in 2027, rising to about 10 million by 2034. Many of those patients will still come in for care — at hospitals, which must treat emergencies regardless of coverage, and at FQHCs, which serve everyone regardless of ability to pay.

Why 2027 is the turning point

H.R. 1 was signed in July 2025, but most of its Medicaid eligibility changes were written to start on January 1, 2027. CBO’s estimates show the effect: about 1.3 million more uninsured in 2026, then a jump to 5.2 million in 2027 as the new rules take hold, and 10 million by 2034.

CBO attributes the largest share to work requirements for expansion adults (5.3 million by 2034, before interactions), followed by limits on provider taxes (1.2 million) and more frequent redeterminations (700,000). For the full list of provisions and dates, see our section-by-section guide to H.R. 1’s Medicaid changes.

How each change turns into an unpaid encounter

1. 01
   Six-month renewals create more coverage gaps

   Expansion adults renew twice a year instead of once. Every renewal is a chance for coverage to lapse over paperwork, even when the patient is still eligible. A visit during that gap closes as self-pay.
2. 02
   Work requirements add a documentation hurdle

   Expansion adults ages 19–64 must show 80 hours a month of work, school or community service unless exempt. Patients who miss the reporting lose coverage — and many will still need care.
3. 03
   The safety valve gets smaller

   Retroactive coverage has long let providers bill Medicaid for care up to three months before an application. For applications on or after January 1, 2027, that drops to one month for expansion adults and two for other groups. Encounters outside the window stay uncompensated.
4. 04
   The care still happens

   Hospitals must screen and stabilize emergency patients regardless of insurance. FQHCs must serve everyone regardless of ability to pay. When coverage drops, the visit doesn’t disappear — the payment does.

Hospitals vs. FQHCs: where the pressure lands

Both carry more unpaid care, but through different doors.

What the projections say

Hospitals. In a December 2025 analysis, Premier Inc. projected a $68.5 billion revenue impact on hospitals across 2026 and 2027, including a $12.5 billion rise in uncompensated care — from $32.4 billion to $44.9 billion. Texas, Florida, California, New York and Georgia face the largest totals.

Rural hospitals. The Sheps Center at UNC identified hundreds of rural hospitals at risk under H.R. 1, with 83 at the highest relative risk of financial distress. Earlier Urban Institute modeling, done before final passage and including the expiration of enhanced marketplace subsidies, put rural hospitals’ share of new uncompensated care at more than a quarter of the national increase.

Health centers. Health centers served 32.4 million patients in 2024, and 15.6 million of them had Medicaid. With Medicaid making up 60% of health center revenue, researchers at George Washington University’s Geiger Gibson Program expect the cuts to push more centers into operating losses.

Projections differ by method, time period and whether they include other policy changes, such as the end of enhanced marketplace subsidies. Use them as a direction, not a forecast for your facility. Your own exposure depends on your state’s choices, your payer mix and how many of your Medicaid patients are expansion adults.

Not every uncompensated encounter stays that way

Coverage that lapses over paperwork often comes back. Patients re-apply, win appeals, get reinstated or have a payer added later — and some of those changes reach back to the date of service. When they do, an encounter written off as self-pay becomes billable to Medicaid.

H.R. 1 makes these changes more frequent, but it also gives providers less time to act on them. With a shorter retroactive window, the change has to be caught quickly, while the filing window is still open.

Eligibility checks at registration still matter — they confirm coverage at the patient level on the day of the visit. RetroCAID® works after the fact, at the encounter level: it monitors the Medicaid Benefit Profile behind every uncompensated encounter daily and sends a Patient Benefit Alert when a change makes it reimbursable. Hospitals can see how this works in how hospitals can recover missed Medicaid reimbursements.

H.R. 1 and uncompensated care, answered

More uncompensated encounters. Less time to recover them.

RetroCAID monitors every uncompensated encounter daily for the coverage changes that make it reimbursable — 100% contingency, paid only after you’re reimbursed.

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