How The 2026 Midterms Could Impact Medicaid Funding And Your Local Hospital

The midterm elections are over, and Democrats are projected to win control of both the House and Senate, Medical Economics reports. For many voters, healthcare costs were a deciding issue.

However, a new Congress won’t instantly change things at your local hospital. Lawmakers aren’t seated until January, President Trump keeps his veto and Senate rules still let the minority block most bills. Meanwhile, major Medicaid changes are already on the calendar, and they’ll take effect before the new Congress can act.

That matters for Black patients, who already face barriers to care, from cost to doctors who don’t listen. Here’s what the midterm elections could mean for local hospitals, especially safety-net hospitals that serve Black and lower-income communities, according to experts.

The Medicaid shuffle: What changing rules mean for hospital budgets

Medicaid is a lifeline for hospitals that serve lower-income patients. Now, the 2025 federal budget law, known as the One Big Beautiful Bill Act, is changing the rules.

Starting by Dec. 31, 2026, most adults ages 19 to 64 who gained coverage through Medicaid expansion must show they work, volunteer or attend school at least 80 hours a month, according to KFF. Some states could get permission to delay until the end of 2028. In addition, these adults will have to renew their coverage every six months instead of once a year.

The Congressional Budget Office estimates the work requirements alone will leave 5.3 million more people uninsured by 2034. More frequent renewals could leave another 700,000 people uninsured, according to CBO estimates cited by KFF. That’s often because of paperwork, like a missed letter or a missing pay stub, not because people stopped qualifying.

That’s why the midterm elections at the state level matter, too. “The governors and state legislators elected this week decide how strictly they’re enforced and how much help people get to stay enrolled,” said Joel Selanikio, MD, a practicing pediatrician at Georgetown and Mary’s Center in Washington, D.C., and a former CDC epidemiologist. “Strict enforcement means more uninsured patients in safety-net ERs and more unpaid bills.”

Community health centers are already preparing for the paperwork. For example, Lynn Community Health Center, a federally qualified health center in Massachusetts, is adding AI tools to help its enrollment staff keep up with the extra workload, according to CEO Brenda Rodriguez‘s team. Medicaid is the center’s largest source of revenue.

The law also changes how states pay for Medicaid. Many states fund their share partly through taxes on hospitals and other providers, and some send extra “state-directed” payments to hospitals that serve many Medicaid patients. Starting in October 2027, the law phases down those provider taxes. Then, starting in 2028, it trims the extra payments, KFF reports.

Rural hospitals are especially at risk

Rural hospitals are especially exposed. In fact, 46% of rural hospitals already lose money, and 432 are vulnerable to closure, according to a 2026 report from the healthcare advisory firm Chartis, as reported by Fierce Healthcare. Since 2010, 182 rural communities have lost inpatient hospital care through closures or conversions.

To soften the blow, the law created a $50 billion Rural Health Transformation Program that provides grants to states from 2026 through 2030. However, that money is spread across all 50 states over five years.

When a hospital or ER closes, the effects can be serious. For example, a Health Affairs study of California hospitals found that patients admitted to hospitals near a recently closed ER had 5% higher odds of dying. For heart attack patients, the odds were 15% higher.

Preparing for a drop in coverage

The enhanced Affordable Care Act premium tax credits expired at the end of 2025 after Congress didn’t extend them. As a result, about 2.6 million fewer people had Marketplace coverage in February 2026 than a year earlier, according to an AP analysis reported by Chief Healthcare Executive. Florida saw the biggest drop, with more than 440,000 fewer people covered.

Hospitals are feeling it. For instance, HCA Healthcare, the nation’s largest for-profit hospital chain, said ACA admissions fell 19% from a year earlier, while uninsured patients made up 10.5% of its volume, according to Healthcare Dive. The company has lost about $950 million in pretax earnings this year from ACA coverage losses. And when uninsured patients put off care, their health problems often get worse and more expensive to treat by the time they reach the ER.

After the midterm elections, Democratic leaders said they’ll push to bring back the tax credits and reverse the Medicaid cuts. Still, any deal will need support from the White House and enough Senate Republicans, so relief isn’t guaranteed.

Price transparency and accountability: The new bipartisan focus

No matter what the midterm elections decided, hospital prices will stay under the microscope. Both parties have backed efforts to make healthcare prices easier to see and compare.

For example, hospitals are already required to post their prices online. In 2026, new federal rules added requirements for accuracy and executive accountability, and 519 hospitals received warning letters, according to Becker’s Hospital Review. However, only 28 hospitals have been fined since the rule took effect.

Meanwhile, the federal No Surprises Act protects patients from most surprise bills for emergency care and for out-of-network doctors at in-network hospitals. Congress has also cracked down on drug middlemen known as pharmacy benefit managers. In fact, the Labor Department finalized a rule in October requiring them to disclose how they’re paid.

Changing how hospitals get paid

Currently, Medicare often pays more for the same service when it is provided at a hospital-owned clinic rather than an independent doctor’s office. Site-neutral payments would change that.

“Site-neutral payment would have Medicare pay the same for a routine visit or scan whether it happens in an independent office or a hospital-owned clinic,” Selanikio said. “Patients would see lower bills and fewer facility fees.” On the other hand, he said hospitals would lose revenue from the practices they’ve bought, “and some would cut or close them.”

The idea already has momentum. For instance, Medicare has applied site-neutral pay to some clinic visits and drug administration. It has also proposed cutting pay by 60% for X-rays and MRIs without contrast at off-campus hospital clinics, according to KFF. Broader reforms could save Medicare about $157 billion over 10 years, the CBO estimates.

Hospitals argue those payments help fund round-the-clock emergency care. Notably, most rural hospitals would be exempt from the proposed imaging cut. Because site-neutral pay “has support in both parties,” Selanikio said, “it could move in the next Congress.”

Healthcare beyond Congress

Some of the biggest healthcare decisions in the midterm elections happened on state ballots. For example, South Dakota voters rejected an amendment that would have weakened the state’s constitutional protection for Medicaid expansion, according to Medical Economics. Supporters said the vote protects coverage for more than 30,000 residents.

In California, voters rejected Proposition 44, which would have required private nonprofit community clinics to spend at least 90% of their revenue on patient care. Meanwhile, Georgia’s governor-elect, Keisha Lance Bottoms, has promised to replace the state’s partial Medicaid program, Georgia Pathways, with full expansion, according to Medical Economics. However, she’ll need the Republican-led legislature on board. And under federal law, any expansion would still come with the new work requirements, GPB reported.

Similarly, local races matter, too. City and county leaders set public health budgets, and state lawmakers decide how to carry out Medicaid’s new rules. As a result, the people you vote for closest to home often shape what care looks like in your neighborhood.

Bottom line

The midterm elections shifted power in Congress, but major Medicaid changes are still set to take effect in January, and any fix for expired ACA subsidies will require cross-party deals. For local hospitals, especially safety-net hospitals, more uninsured patients mean more unpaid care. Stay on top of your coverage, and know your options if you lose it.

Frequently Asked Questions

Will hospital prices become more transparent after this election?

Price transparency has support from both parties, so expect continued pressure on hospitals to post clear, accurate prices. Enforcement has been limited, with only 28 hospitals fined since the rule took effect, according to Becker’s Hospital Review.

Why are state elections just as important as Congress for healthcare?

Governors and state lawmakers decide how to carry out Medicaid’s new work requirements and eligibility checks, whether to expand Medicaid and how to fund public health, so state results can affect your coverage and local hospitals faster than Congress can.

Citations

Cass A. Hospital price transparency in 2026: 4 things to know. Becker’s Hospital Review. Published July 15, 2026. https://www.beckershospitalreview.com/finance/hospital-price-transparency-in-2026-4-things-to-know/

Fierce Healthcare. Nearly half of rural hospitals in the red, 432 vulnerable to closure, report finds. Accessed November 4, 2026. https://www.fiercehealthcare.com/providers/46-rural-hospitals-red-432-vulnerable-closure-report-finds

Gratas S. Medicaid work requirements are here to stay no matter who wins Georgia’s governor’s race. GPB. Published October 1, 2026. https://www.gpb.org/news/2026/10/01/medicaid-work-requirements-are-here-stay-no-matter-who-wins-georgia-governors-race

Halleman S. HCA’s bottom line suffers as ACA coverage losses mount. Healthcare Dive. Published October 28, 2026. https://www.healthcaredive.com/news/hcas-bottom-line-suffers-aca-coverage-losses-mount/873032/

Health Resources and Services Administration. Health Center Program Compliance Manual, Chapter 9: Sliding fee discount program. Accessed November 4, 2026. https://bphc.hrsa.gov/compliance/compliance-manual/chapter9

Internal Revenue Service. Financial assistance policies (FAPs). Updated December 28, 2025. https://www.irs.gov/charities-non-profits/financial-assistance-policies-faps

KFF. Health provisions in the 2025 federal budget reconciliation law: Medicaid. Updated August 22, 2025. https://www.kff.org/report-section/health-provisions-in-the-2025-federal-budget-reconciliation-law-medicaid/

Levinson Z. The Trump administration continues to advance incremental site-neutral payment reforms. KFF. Published July 6, 2026. https://www.kff.org/quick-insights/the-trump-administration-continues-to-advance-incremental-site-neutral-payment-reforms/

Littrell A. Democrats win Congress as voters in six states settle health care ballot measures. Medical Economics. Published November 4, 2026. https://www.medicaleconomics.com/view/democrats-win-congress-as-voters-in-six-states-settle-health-care-ballot-measures

Liu C, Srebotnjak T, Hsia RY. California emergency department closures are associated with increased inpatient mortality at nearby hospitals. Health Affairs. Published August 2014. https://www.ucsf.edu/news/2014/08/116461/higher-chance-hospital-death-found-areas-where-emergency-departments-have

Southwick R. Affordable Care Act coverage plunges in 2026: Questions and answers. Chief Healthcare Executive. Published July 17, 2026. https://www.chiefhealthcareexecutive.com/view/affordable-care-act-coverage-plunges-in-2026-questions-and-answers

U.S. Centers for Medicare & Medicaid Services. Emergency Medical Treatment & Labor Act (EMTALA). Accessed November 4, 2026. https://www.cms.gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act

U.S. Centers for Medicare & Medicaid Services. No Surprises: Understand your rights against surprise medical bills. Accessed November 4, 2026. https://www.cms.gov/nosurprises