State Medicaid systems are scrambling to prepare for painful cuts under the One Big Beautiful Bill Act, leaving private insurers with mounting financial pressure and state officials with few options for relief 16 months before the new policies take effect.

The megabill represents the largest cuts to Medicaid in its 60-year history — roughly $1 trillion — and while most of the changes won’t take effect until after next year’s midterm elections, the state-run programs are already facing a time crunch.

Matt Salo, the former executive director of the National Association of Medicaid Directors and CEO of the health consulting firm Salo Health Strategies, predicted many states will request delays.

“The real question is, will the administration grant that? Because it's entirely up to the administration to say yes or no to that,” Salo added. “I might venture to say, you know, if you have 25 blue states coming in and saying, ‘Hey, give us two more years because we really need that much time,’ the administration might not be all that keen to grant it.”

Much of the cuts come from new, strict work requirements and restrictions on state-levied taxes on health providers, which account for a significant amount of revenue for states to fund their Medicaid programs.

Beginning on Jan. 1, 2027, the megabill will require that people who are not already working at least 80 hours a month be denied coverage. While many Medicaid enrollees will likely remain eligible for coverage under the new work requirement, many are expected to

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