Louisiana ranks last in health as Medicaid changes put rural care under pressure

BATON ROUGE — Louisiana already ranks 50th among the states in overall health. Now the state is preparing for major changes to Medicaid that are expected to reduce enrollment and federal spending compared with what would have occurred under previous law.

For a state already at the bottom of the nation's health rankings, the changes raise a consequential question: What happens to access to health care when fewer people have Medicaid coverage and rural providers are already struggling to survive?

The answer will not be known immediately. But the policies, the votes that created them and the government's own projections provide a clear picture of what Louisiana is facing.

The changes stem largely from the federal reconciliation law signed by President Donald Trump in 2025. Republicans controlled Congress when the legislation passed.

The Congressional Budget Office estimates that the law will reduce federal Medicaid spending by about $1.2 trillion over 2026 through 2035 compared with what would have been spent under previous law. CBO also projects that 12.9 million fewer people will be enrolled in Medicaid in 2034 and that 7.5 million more people will be uninsured that year than would have been the case without the law.

Those are projections, not a count of people who have already lost coverage.

But they illustrate the potential scale of the changes coming to Louisiana.

Louisiana starts from the bottom

The timing is significant because Louisiana is already facing serious health challenges.

The latest America's Health Rankings annual report places Louisiana 50th in the nation for overall health, making it the least healthy state in the country.

The state also performs poorly on health outcomes and health behaviors and continues to struggle with poverty and other social conditions that affect health.

That means Louisiana is not entering the Medicaid changes with a strong health care system that can easily absorb a loss of coverage.

It is entering them with a population already experiencing some of the nation's worst health outcomes.

What the federal law actually does

The new federal law does not eliminate Medicaid.

Federal Medicaid spending is still expected to grow over the next decade as the cost of medical care rises and the program continues serving millions of Americans.

What changes is the amount the federal government is expected to spend compared with previous law and, importantly, the number of people expected to remain enrolled.

The law changes eligibility and enrollment procedures, places new restrictions on certain Medicaid financing arrangements and creates a new community-engagement requirement for certain adults.

Beginning in 2027, certain Medicaid expansion adults ages 19 through 64 generally will have to demonstrate an average of 80 hours a month of work, community service, education, job training or another qualifying activity to maintain coverage.

There are exemptions and special rules, meaning the requirement does not apply to every Medicaid recipient.

Louisiana must implement the federal requirements.

Why Republicans say the changes are necessary

Republicans who supported the legislation say Medicaid has grown beyond what they believe was its intended purpose and that the program needs stronger safeguards.

They argue the changes will reduce waste, fraud and improper enrollment while requiring certain able-bodied adults to work, attend school, receive job training or participate in qualifying community activities.

Republican lawmakers also say the changes are intended to protect Medicaid for people they consider most dependent on the program, including children, pregnant women, seniors and people with disabilities.

That is the Republican rationale for the legislation.

The Congressional Budget Office, however, projects that the changes will result in millions fewer people receiving Medicaid coverage and millions more people without health insurance.

Louisiana's congressional delegation had a direct say

The legislation was not simply a decision made by politicians from other states.

Louisiana's congressional delegation voted on it.

In the Senate, Republican John Kennedy voted for the legislation.

Republican Sen. Bill Cassidy voted against the final Senate version.

In the House, all four Louisiana Republicans voted for the legislation:

• Mike Johnson, Republican, 4th Congressional District and Speaker of the House
• Steve Scalise, Republican, 1st Congressional District
• Clay Higgins, Republican, 3rd Congressional District
• Julia Letlow, Republican, 5th Congressional District

Louisiana's two Democratic House members, Troy Carter and Cleo Fields, voted against the bill.

The votes are significant because the law will directly affect Medicaid beneficiaries, health care providers and state government in Louisiana.

They also demonstrate that the state's Republican delegation was not unanimous.

Cassidy, a physician and longtime health policy voice in the Senate, opposed the final measure.

Louisiana's Medicaid rolls have already changed

The coming federal requirements are not the only reason Louisiana's Medicaid enrollment has changed.

The state began resuming Medicaid eligibility reviews in 2023 after the federal government ended the pandemic-era continuous enrollment requirement.

Large numbers of Louisianians were subsequently removed from Medicaid.

But the numbers require context.

Louisiana's own data show that many people who were disenrolled later returned to the program.

During the first year of the state's Medicaid renewal process, more than 227,000 people were disenrolled and then reenrolled within 180 days or less.

That phenomenon is known as Medicaid “churn.”

It means a person appearing in a disenrollment figure was not necessarily permanently determined to be ineligible.

Some people lost coverage because they did not complete the renewal process or could not provide the required information and later regained coverage.

That distinction matters when describing Louisiana's Medicaid losses.

How could the changes hurt people?

The most direct potential consequence is loss of health coverage.

If someone loses Medicaid and does not have access to employer insurance or cannot afford private coverage, that person may become uninsured.

Being uninsured does not automatically mean someone will become sick.

But it can make health care more difficult to afford.

A person may postpone a doctor's appointment.

A prescription may become too expensive.

A recommended test may be delayed.

A chronic condition such as diabetes, high blood pressure or asthma may go untreated.

A problem that could have been managed in a doctor's office could eventually require emergency treatment.

The Congressional Budget Office projects that most people who lose Medicaid because of the new federal policies will become uninsured rather than immediately moving into another source of coverage.

For Louisiana, that matters because the state already has substantial health problems.

Rural Louisiana faces another challenge

The consequences could be particularly significant in rural communities.

A large city may have numerous doctors, urgent-care centers and hospitals.

A small rural community may have one primary-care clinic.

If that clinic closes or stops accepting Medicaid, patients may have to travel to another town or parish for routine medical care.

For people without reliable transportation, distance can become a health care barrier.

That is one reason Louisiana lawmakers approved a separate policy designed to strengthen independent rural clinics.

Louisiana is actually increasing rural Medicaid payments

Act 859, passed by the Louisiana Legislature, increases Medicaid reimbursement for independent rural health clinics by $41.50 per encounter in fiscal year 2026-27 and another $41.50 in fiscal year 2027-28, subject to federal approval of the new payment structure.

The rate will also receive future adjustments based on health care inflation.

The legislation was designed to address a longstanding disparity between independent rural clinics and certain hospital-affiliated rural clinics.

The estimated additional state general-fund cost is approximately $2.66 million.

That means Louisiana is doing something that may initially appear contradictory.

The state is increasing Medicaid payments to rural clinics while the federal government is changing Medicaid in ways expected to reduce enrollment and federal spending.

The reason is that Louisiana lawmakers say independent rural clinics need more money simply to remain financially viable.

The cost of keeping a rural clinic open

Herndon “Buzz” Jeansonne has experienced that financial pressure firsthand.

Jeansonne began acquiring rural clinics in Avoyelles Parish in 2006 and eventually operated five family medicine practices in Cottonport, Simmesport, Mansura, Marksville and Palmetto.

He said Medicaid paid approximately $70 to $80 per visit when he started.

By 2025, his clinics were receiving between $109 and $125 per Medicaid visit, depending on the location, according to Louisiana Department of Health data.

But the cost of operating the clinics had increased.

Jeansonne said he once could recruit a nurse practitioner for approximately $65,000.

Later, he said, he had to offer about $120,000 plus bonuses to attract applicants.

Technology costs, staffing expenses and administrative requirements also increased.

Eventually, Jeansonne sold his clinics to MyTown Health Partners, a Pittsburgh-based health care company backed by private equity.

He continued treating patients but no longer controlled the business operations in the same way.

Jeansonne said the new Louisiana reimbursement structure could have changed his decision to sell.

Hospitals say they are vulnerable, too

Independent clinics are not the only rural providers concerned about the Medicaid changes.

Rural hospitals say they also face financial pressure.

Hospital-affiliated rural clinics operate under different Medicaid reimbursement rules, and some receive substantially higher payments than independent clinics.

Hospital representatives argue that the comparison is not simply about the amount paid for a doctor's visit.

Hospitals maintain emergency departments, inpatient services, diagnostic testing and specialty care.

They also provide services that independent primary-care clinics generally do not.

Rural hospital leaders worry that giving independent clinics substantially higher reimbursement could make it more difficult for hospitals to compete for physicians and other health care workers.

That creates a second potential problem.

Rural clinics and rural hospitals may be competing for patients, doctors and Medicaid dollars even though both are necessary parts of the rural health system.

The danger of losing coverage

The biggest concern is not simply the loss of an insurance card.

It is what can happen afterward.

A person without coverage may delay care.

A rural resident may have difficulty finding another provider.

A clinic could lose revenue.

A hospital could see more uninsured patients.

Emergency rooms could become a substitute for primary care.

And a community could eventually lose a health care provider.

None of those outcomes is guaranteed by the federal law.

But they are among the potential consequences policymakers must consider as Medicaid enrollment declines.

Louisiana has another source of help

The federal government is not providing only Medicaid reductions.

Louisiana also has received substantial federal support through the Rural Health Transformation Program.

The state has been awarded more than $208 million in initial federal rural-health funding, with additional funding potentially available over several years.

The money is intended to strengthen rural health care, expand access, improve technology and support new approaches to delivering care.

That funding could help offset some of the pressures facing rural providers.

But it does not replace Medicaid coverage for someone who becomes uninsured.

That distinction is important.

A rural-health grant can help a clinic buy equipment, improve infrastructure or expand services.

It does not necessarily pay the medical bill of a patient who no longer has insurance.

So will this hurt Louisiana?

That question cannot honestly be answered with an absolute yes or no yet.

The federal changes have not fully taken effect.

CBO's projections indicate that millions nationally will lose Medicaid coverage and that millions more will become uninsured.

But the effect on Louisiana's health outcomes will depend on how many residents lose coverage, how many obtain other insurance, how effectively the state implements the new rules and whether rural providers receive enough financial support to remain open.

What can be said now is that Louisiana has little room for error.

It is already ranked last in the nation for overall health.

It has rural communities where medical providers are scarce.

It has families struggling with poverty and chronic disease.

And it is entering a period in which fewer people are expected to receive Medicaid coverage.

A test for Louisiana's health care system

Republicans say the federal changes are necessary to control spending, eliminate waste, tighten eligibility and encourage able-bodied adults to work or participate in qualifying activities.

Critics argue that reducing Medicaid enrollment will leave more people uninsured and place additional pressure on health care providers.

Both arguments are now part of the policy debate.

But Louisiana residents will ultimately judge the changes by what happens in their communities.

Can they find a doctor?

Can they afford their medication?

Can a rural clinic stay open?

Can a hospital continue operating its emergency department?

Can a working family obtain health insurance if Medicaid disappears?

Those questions are particularly urgent in a state that already holds the nation's worst overall health ranking.

Louisiana is therefore facing a complicated health care experiment.

Washington is tightening Medicaid eligibility and reducing projected federal spending.

Baton Rouge is increasing payments to independent rural clinics.

Federal officials say the changes will make Medicaid more sustainable and reduce improper spending.

Health care advocates warn that losing coverage could make it harder for vulnerable residents to receive care.

And Louisiana's own congressional delegation is on record.

Five of the state's six Republican members of Congress voted for the final federal legislation, while Sen. Bill Cassidy voted against it. Louisiana's two Democratic House members also voted against it.

The consequences will unfold over the next several years.

But for a state already ranked No. 50 in the nation for health, the stakes are unusually high.

Louisiana does not simply need more health care money. It needs more people able to receive health care, more providers willing to practice where they are needed, and a system capable of keeping both patients and providers from falling through the cracks.