Public Citizen: 446 hospitals in 44 states face closure risk from $1 trillion in Medicaid cuts

Public Citizen's Congress Watch division published a hospital risk analysis on April 1, 2026. Researcher EOEileen O'Grady examined financial data from approximately 95% of U.S. hospitals covering fiscal years 2022-2024. She identified 446 hospitals across 44 states and 🏛️D.C. as 'at risk' using two criteria: at least 20% of revenue from Medicaid and low-income government programs, and operating at a loss in recent years. The 446 at-risk hospitals served approximately 6.6 million patients in 2024 and employed 275,000 direct patient-care workers.

The cuts stem from the One Big Beautiful Bill Act (OBBBA), a House Republican reconciliation package with approximately $1 trillion in Medicaid reductions over 10 years. Budget reconciliation allows it to pass the Senate with a simple 51-vote majority. Primary Medicaid cuts: mandatory work requirements for able-bodied adults aged 19-64 (effective 2027); limits on provider taxes states use to draw down federal matching funds (effective 2028); changes to the federal matching rate; and elimination of the enhanced ACA Medicaid expansion matching rate.

The OBBBA includes $50 billion in rural hospital support. But the Rural Policy Institute projected rural Medicaid cuts at approximately $137 billion — nearly three times the offset. About 60% of the 446 at-risk hospitals are in urban areas, but rural hospitals face disproportionate impact because rural communities have higher rates of Medicaid enrollment, and rural hospitals often have no other payer mix to offset losses.

Work requirements would require able-bodied Medicaid enrollees aged 19-64 to document 80 hours per month of work, education, or community service. Research on 💎Arkansas's 2018 work requirement found that most people who lost coverage were already working but couldn't navigate the paperwork. An Urban Institute analysis estimated OBBBA work requirements would cause approximately 5.2 million people to lose Medicaid coverage by 2034. The CBO projected 13-17 million total coverage losses over 10 years.