On the Margins -- Apr 01: States pay Deloitte, Optum to cut Medicaid rolls
On the Margins
Your daily health economics & actuarial brief
Wednesday, April 01, 2026
What's happening today
| ■ | States are paying Deloitte, Optum, and others millions to implement Medicaid eligibility changes under the One Big Beautiful Bill Act. |
| ■ | GAO found CMMI tested 70 payment models but expanded only four nationwide. |
| ■ | KFF estimates 17,000 federally funded clinics could lose $32 billion over five years. |
Key Stories
States pay Deloitte, Optum to cut Medicaid rolls
States are paying Deloitte, Accenture, and Optum millions to implement the One Big Beautiful Bill Act, which is expected to shrink Medicaid enrollment. MedCity, citing Urban Institute, said the law could push 5 million to 10 million people off Medicaid by 2028, depending on how states handle work requirements and eligibility rules. KFF separately published a tracker for 2025 reconciliation-law Medicaid work requirement policies. Administrative spend rises now; MCOs and providers later absorb membership volatility, capitation revenue pressure, and more uninsured care.
GAO: CMMI scaled 4 of 70 models nationwide
GAO said CMS' Innovation Center has tested 70 payment models and expanded only four nationwide. CMS also opened applications for the Long-term Enhanced ACO Design, or LEAD, model. The read-through is straightforward: new APM launches keep coming, but the national scale rate remains thin. For finance teams, that argues for discounting early model headlines until participation terms and downside economics are clearer.
Federally funded clinics face $32B five-year hit: KFF
KFF Health News reported that 17,000 federally funded clinics could lose $32 billion over five years under GOP-backed fiscal policies. The same report said more uninsured patients would rely on those clinics for low-cost care. That means lower revenue and more uncompensated demand for already thin-margin providers. Separately, Cedar found uninsured patients drive nearly 40% of healthcare collections, and 30% of respondents said payment options are unaffordable.
Significant Digit
CMS projects enhanced ACA subsidy expiration could cut direct-purchase enrollment by 4.7 million in 2026, reshaping exchange risk pools and pricing.
In its latest national health expenditure forecast, CMS projects direct-purchase enrollment will fall 12.3% in 2026 when the enhanced Marketplace subsidies expire. That is not just a coverage story -- it is adverse selection, premium pressure, and more uncompensated-care risk showing up at once. For ACA carriers, providers, and state policymakers, the policy cliff is now a utilization and margin variable.
Other Relevant Headlines
Policy & Regulation
| Tech nonprofit sues CMS over Medicare AI prior authorization pilot | Healthcare Dive |
| Treasury focuses on healthcare fraud in advisory, proposed rule | Inside Health Policy |
| Health experts call for changes to the No Surprises Act | MedCity News |
Provider Economics
| Nearly half of US hospital markets are entirely controlled by 1 or 2 health systems: KFF | Fierce Healthcare |
| BCBS Texas and Memorial Hermann near contract deadline | Becker's Payer |
| Bipartisan bill would cap Medicare physician pay cuts | Modern Healthcare |
Pharmacy & Drug Pricing
| CAP says TrumpRx may hike costs; CMS official emphasizes transparency over discounts | Inside Health Policy |
| AbbVie and Novartis sue over new Washington 340B law that blocks pharma claims requirements | Inside Health Policy |
Payer Operations
| Anthem BCBS California extends pause on E/M policy until May 1 | Becker's Payer |
ICYMI (Recent Key Stories)
- Alabama bans breast imaging cost-sharing in 2027 -- A new Alabama law will eliminate patient cost-sharing for breast imaging starting in 2027. (2026-03-31)
- AHIP sells affordability through chronic-condition management -- AHIP is promoting chronic-disease management as a way to improve care and lower healthcare costs. (2026-03-30)
- Judge lets MA broker-kickback suit against Aetna, Humana, Elevance proceed -- A judge allowed a lawsuit alleging Medicare Advantage broker kickbacks by major insurers to move forward. (2026-03-27)
- KFF finds 19% in-network denial rate in 2024 HealthCare.gov plans -- KFF reported that 2024 HealthCare.gov plans denied 19% of in-network claims on average. (2026-03-26)
- CMS pairs Minnesota Medicaid fix with tougher federal fraud funding threat -- CMS approved a Minnesota Medicaid funding fix while warning states over federal fraud-funding compliance. (2026-03-25)
- Sutter's Allina acquisition creates a $26B nonprofit across three states -- Sutter's planned Allina acquisition would form a $26 billion nonprofit health system spanning three states. (2026-03-24)
- Klomp floats automatic Medicare Advantage enrollment as policy option -- Klomp suggested automatic Medicare Advantage enrollment as a possible future policy approach. (2026-03-23)
- Providence puts its health plan on the block, or close to it -- Providence is exploring a sale or similar strategic option for its health insurance business. (2026-03-20)