Introduction: The 2025 Budget Reconciliation Bill substantially reduces federal Medicaid funding via work requirements and more frequent recertification. These eligibility restrictions will disproportionately impact young and socially vulnerable enrollees served by the Medicaid program.
Methods: We built a monthly, state-level Medicaid panel of adult Medicaid enrollment from CMS Performance Indicators. For each state we defined baseline enrollment and identified the adult expansion share and treated remaining adults as non-expansion. We modeled two provisions. First, one-time work-requirement exits among expansion adults. Second, semiannual redetermination–induced churn implemented as an uplift to baseline monthly churn. We paired coverage losses with state-level BRFSS 2022 screening prevalences to estimate missed screenings among screen-eligible Medicaid adults. Missed screenings were converted to incident cancers using two-year risks, then mapped to stage shift and deaths using parameters drawn from CISNET modeling used by USPSTF and SEER calibration.
Results: Over the two‑years post-implementation, an estimated 7.5 million (95%CI 5-10.8 million) Medicaid adults eligible for breast or colorectal cancer screening will lose coverage. We estimate 401,862 (95%CI 320990–490856) missed mammograms and 600,719 (95%CI479863–733657) missed colorectal screening tests. Missed screening is projected to result in 1045 (95%CI 835–1276) undetected breast and 661 (95%CI 528–807) undetected colon cancers. Among these, 155 (95%CI 124–189) breast and 93(95%CI 74–114) colon cancers are estimated to present at an advanced stage rather than early through screening. We estimate 114 (95%CI 35-85) potentially avoidable cancer deaths. There was substantial variation across states in projected missed screenings and subsequent cancer-related outcomes. Rates of missed screenings per Medicaid enrollee were highest in Maine, California, and Oregon and lowest in North Carolina, Massachusetts, and Utah producing corresponding differences in excess late-stage cancers and deaths.
Conclusions: Projected Medicaid coverage losses translate into substantial missed cancer screening resulting in more advanced disease diagnosis. National averages mask a greater than 10-fold variation across states, with steep shortfalls in some large states and smaller impacts where safety-net programs support uninsured screening. These findings highlight the scale of preventable morbidity and illustrate how national policy can result in costly health consequences.
Learning Objectives:
Describe how proposed Medicaid eligibility restrictions under the 2025 Budget Reconciliation Bill could affect cancer screening access and outcomes among low-income adults.
Explain the modeling approach used to estimate the impact of Medicaid coverage losses on missed cancer screenings, stage migration, and mortality across U.S. states.
Interpret state-level variation in projected cancer screening shortfalls and discuss policy mechanisms that could mitigate inequitable health consequences.
