Medicaid cuts in ‘Big Beautiful Bill’ could devastate Missouri’s rural hospitals, drive coverage losses
Mitchell Kaminski
COLUMBIA, Mo. (KMIZ)
The recently passed federal budget bill, known officially as H.R. 1 or the “One Big Beautiful Bill” is drawing criticism from Missouri health care leaders and public officials, who warn that the legislation’s deep Medicaid cuts could lead to widespread coverage losses and strain already struggling rural hospitals.
The bill, now awaiting President Donald Trump’s signature, includes nearly $1 trillion in cuts to Medicaid and other health programs over the next decade, according to the nonpartisan Congressional Budget Office. That reduction is expected to impact nearly 17 million people nationwide, including tens of thousands in Missouri.
Kansas City Mayor Quinton Lucas said the bill could exacerbate already existing health disparities in the state.
“We have real public health needs that if we’re kicking tens of thousands of Missourians off of Medicaid, will be exacerbated,” Lucas said. “I visited with our safety net hospital in Kansas City, the university health system. They talked about how they will have to make very difficult choices on the services they provide. Most of their recipients are on Medicaid.”
In June, Lucas urged Missouri senators to consider the real-world effects of the cuts.
“Listen to the people of a place like Lexington, Missouri, where our senior senator grew up, listen to the people there who need access to health care, who don’t want to have to drive miles and miles and incredibly long distances to have a safety net hospital that is still open and hasn’t been destroyed by health care cuts,” Lucas said.
The Missouri Hospital Association estimates the legislation will cut as much as $5.7 billion from MO HealthNet — the state’s Medicaid program — throughout the next 10 years. The cuts include a phased reduction in provider taxes starting in 2028 and caps on state-directed hospital payments, which together could result in a $1.2 billion annual loss to the state’s health care system, when fully implemented.
Despite support from Republicans Gov. Mike Kehoe and Sen. Josh Hawley for a five-year, $50 billion Rural Health Transformation Program included in the bill, the MHA projects that any gains will be outweighed by the Medicaid reductions by 2030.
Rural access in jeopardy
Missouri is already grappling with a rural health care crisis. From 2014 to 2023, 12 hospitals in rural counties closed, according to the Missouri Department of Health and Senior Services. The state has 161 licensed hospitals serving a population that ranks 18th in the U.S.
Missouri House Minority Leader Ashley Aune (D-Kansas City) said the bill could accelerate that trend.
“Rural hospital closures, that is an epidemic in this state,” Aune said. “There are folks who have to drive hours to receive emergency care in this state. Think about that. Think about having a heart attack in rural Missouri and having to drive three, four hours just to receive care somewhere adequate.
“We are talking about life-saving health care access being absolutely denied to Missourians across the state and not for nothing.”
Work requirements could add to coverage losses
The bill also includes work requirements for certain Medicaid recipients, a measure that has been widely criticized by health experts.
Republican Rep. Bob Onder, who practiced medicine for more than 30 years, defended the bill in May, saying that it preserves Medicaid coverage while implementing crucial reforms.
“I can tell you there is a lot of waste, fraud and abuse in the Medicaid program,” Onder told ABC 17 News during a visit to Columbia on May 30. “But what the Big Beautiful Bill did not do is cut Medicaid. It did really two major reforms, both of which I think are a good idea. One is to require regular eligibility checks to make sure that those who are on the rolls are actually eligible. And No. 2 is reform work requirements, modest work requirements for able-bodied working-age adults. The traditional Medicaid is completely unaffected by the bill.”
Onder also insisted the changes wouldn’t leave people uninsured.
“We’re just no longer sending a check to an insurance company for someone who doesn’t exist,” he said. “I think the overwhelming majority of those folks will get jobs. In the 1996 Welfare Reform Act, a study by the Brookings Institute showed 80% of folks got jobs with work requirements. And two years later, on average, family household income had doubled.”
However, Chiquita Brooks, former administrator of the Centers for Medicare and Medicaid Services, said similar work requirement policies have already led to massive coverage losses in states like Arkansas.
“Let’s be clear, establishing work requirements in Medicaid will make it harder for eligible people to keep their coverage,” Brooks said. “In 2018, research shows that about one-in-four Medicaid enrollees in Arkansas lost coverage in the first seven months — about 18,000 people — after the state implemented work requirements.”
Brooks also warned of unintended consequences for families and children.
“I’ve spoken with family caregivers who struggled to keep up with the exemption paperwork so that their disabled relatives can keep their coverage. Parents losing eligibility can inadvertently result in children losing coverage too — as high as 1.5 million children can lose their Medicaid coverage as a result of the work requirements in this bill.”
According to the Center on Budget and Policy Priorities, nearly two-thirds of Medicaid recipients already work.
Impact on Missouri’s health infrastructure
Missouri hospitals rely heavily on Medicaid funding to operate. The University of Missouri System’s financial data shows Medicaid accounted for 24% of payments in 2023, and 16% in 2024.
Aune said removing people from coverage doesn’t just hurt patients — it puts financial pressure on the entire system.
“When folks are removed from health coverage, it drives premiums up. It drives out-of-pocket costs up. And frankly, it compromises the overall quality of care that Missourians receive in this state,” she said.
As the Missouri Hospital Association continues to analyze the bill’s 900 pages, CEO Jon Doolittle said hospitals across the state will need to brace for challenging years ahead.
“Missouri’s share of these cuts will harm those covered by Medicaid, all Missourians’ access to health care, the ability of hospitals to provide services, and our state’s budget,” Doolittle wrote in a statement.
While H.R. 1 offers potential boosts to rural care through the transformation program and adjustments to the Medicare physician fee schedule, the long-term future for Missouri’s most vulnerable patients — and the hospitals that serve them — remains uncertain.