The federal One Big Beautiful Bill Act (OBBBA) is set to cut billions from Medicaid. The effects won’t just be felt in Washington, but in your county, your local emergency department, and health clinic. We’re getting to the heart of those cuts in this episode of Community Health Centers, Unfiltered with Blaire Bryant. Blaire is the legislative director at the National Association of Counties and she explained that while the OBBBA changes may be driven by federal law, the impact is a local problem with rippling effects.
Counties as Payers of Last Resort
Blaire explained how Medicaid is a federal/state program. An often-overlooked health care partner that actually funds Medicaid costs: counties. This means that when the federal government reduces its share, the financial burden trickles down to states and, most critically, to counties. In some states, counties are the lead entity for eligibility verifications for enrollment and re-enrollment, and counties administer “Medicaid services through the health care safety net…the hospitals, the health centers, the long-term care facilities and mental health facilities that provide Medicaid eligible services,” she noted. “Counties play a huge role in running the program and contributing fiscally.”
Throughout the discussion with host and ACH CEO Amanda Pears Kelly, Blaire illuminates a key healthcare truth: counties often serve as the payers of last resort, forced to absorb the costs of uncompensated care. This is particularly challenging for rural communities that are already reliant on Medicaid dollars and have fewer health care resources. It is also challenging given that changes to ACA Marketplace subsidies will make it harder for people who are no longer eligible for Medicaid to afford care on a private plan.
Communities and Health Centers Can Take Action
While the impacts to communities, particularly rural ones will be hard, there are ways to move forward. Blaire pointed to several strategies that community health centers and counties can apply to meet the anticipated need:
Hub and Spoke Health Care Models
Blaire notes that this model often means that a larger county hospital acts as the hub and community health centers serve as health care spokes. CHCs can continue to provide essential primary care and other services in their communities and refer to the larger hospital when needed.
Care Coordination & Integrated Care
Many CHCs have taken on the patient-centered medical home model for patients, but this can also be effective for individuals re-entering society after incarceration. By forming interdisciplinary teams, health centers and county services can work together to ensure individuals are connected to the right care—be it medical, dental, or behavioral health—avoiding more expensive and inappropriate care settings like emergency rooms or jails. This collaborative approach is essential for doing more with less and keeping our communities healthy.
Project and Plan to Take Action Now
Blaire notes several communities that are already planning for impacts in 2028. This information is helping communities like Cook County, IL take action now to begin to maximize resources and plan for the future. With an anticipated 19% cut in Medicaid funding, she notes they are implementing a hiring freeze to help manage costs now and in the future. Other communities are leveraging the “little p” of policy, considering value-based payments reforms and alternative payment models that could help to maximize the remaining amount of Medicaid dollars that they have.
For more insights on what’s ahead, listen to the full episode on Community Health Centers Unfiltered!