In July 2025, the One Big Beautiful Bill Act (OBBBA) mandated significant health care funding cuts and policy changes related to low-income health insurance programs like Medicaid and the Children’s Health Insurance Program (CHIP) administration.
As of April 2026, 1.59 million Americans had lost their Medicaid insurance because of OBBBA-related cuts. Because of the bill, an estimated 13 million more people will lose their insurance over the next three years. Between direct funding cuts and a massive loss of clients, health care providers around the country were understandably left on edge.
And then the no-cause termination letters started to arrive.
Becky Wolery, the founder of the Oregon/Idaho-based mental health clinic, Insight Matters, first got the news in December 2025: her clinic was losing its Oregon Medicaid eligibility. Going forward, Wolery’s Ontario, Oregon-based clinic could no longer accept any new Medicaid patients.
“It was basically a close-down notice,” Wolery said. At the Ontario office, 90% of patients are insured through Medicaid. Even existing patients need to renew their prior authorization every six months. Once their existing authorizations had expired, these patients’ coverage would be denied.
Wolery panicked. Ontario, population 11,645 — the largest of any in eastern Oregon’s expansive Malheur County — was already in a health care desert, despite having the highest rate of Medicaid enrollment of any county in the state.
For years, Wolery had only practiced in Idaho, where she lives. When her clinic had outgrown its first building in Payette, she decided to analyze her patients’ demographic data so she could find a new space that best fit her clientele, only to realize that a huge portion of the patients were paying with Oregon Medicaid, crossing the border from Ontario or elsewhere in Malheur County in order to seek out counseling or substance use treatment. She decided to open a second location in Ontario. In less than a year, they had outgrown the first building and had to relocate into a new, larger space. Since then, her practice has been booming.
Now, a total closure was on the horizon. All this, before Medicaid enrollment had really begun to unwind.
Which Side Are You On?
One year after its passage, the implementation of the many fiscal changes mandated by OBBBA — which have been largely managed by individual states — has had vastly different impacts for communities depending on which side of a state border they find themselves on.
For residents of the Oregon-Idaho boundary area, access to care largely depends on which side of the Snake River a person happens to live on. On the eastern, Idahoan side of the border, 4% of state residents were cut from Medicaid in September 2025. Some behavioral health programs — including some that provide funding for peer support and crisis response teams — were cut, but subsequently refunded. Otherwise, business has continued more or less as usual. Although behavioral health providers are anticipating new restrictions to arrive this July, Idaho has yet to experience any seismic shifts to its health care landscape.
This is largely because Idaho had such limited state-sponsored health care services to begin with; the state’s 19% enrollment rate is well below the national average. And in the rural communities along the Idaho-Oregon border, behavioral health care access has always been limited.
In Weiser, Idaho, across the water from Ontario, there were no mental health care providers practicing in town until the town’s hospital opened a small clinic three years ago. Since then, more clinics have followed — but mostly have sprung up to serve the population being sentenced to court-mandated rehabilitation following drug and alcohol charges. For everyone else, the closest in-patient facility is over an hour away.
“For a small city like us, we have nowhere to take our people that need help,” said Weiser City Clerk Natasha McDaniel. “We just put them in jail. And when they come out, they have a criminal record, and it’s harder to get a job. It’s just a vicious cycle.”
So business may be carrying on in Idaho — but it’s bad business to begin with.
For Oregonians living on the other side of the Snake River, it’s a different story.
In recent years, the Oregon Health Plan, which administers Medicaid for state residents, has significantly expanded Medicaid eligibility. Whereas most states only allow coverage for able-bodied adults below the Federal Poverty Line (FPL) — which is $15,960 for a single person — Oregon enrolls anyone earning less than double the FPL. There have been additional expansions for pregnant people and immigrants.
Because of this, Oregon stands to have the most significant drop in Medicaid enrollment of any state in the nation. In Oregon’s rural areas alone, OBBBA will lead to a $4 billion reduction in Medicaid funding through direct cuts and cuts to Medicaid-covered health care services — though most of these changes won’t begin to be implemented until late 2027, and some won’t take full effect until 2034.
In June 2026, the Oregon Health Authority announced new Medicaid eligibility rules. Beginning in 2027, Medicaid participants will need to renew their coverage every six months (currently, the renewal period is two years). And, beginning in October 2028, copays will be required for many health care services, though emergency care, mental health care, prenatal care, and substance use treatments will be excluded — which will likely reduce access to care even among people who retain Medicaid eligibility. Already, 20% of rural Oregonians delay or skip necessary care due to cost.
And in Malheur County — Oregon’s second largest, and one of its most rural — Medicaid enrollment is disproportionately high, relative to other parts of the state: 50% of residents are currently enrolled in Medicaid or Medicare. Among those enrolled in Medicaid (which provides free insurance to low-income people), the vast majority (almost 80%) are children. Nearly 25% have a disability, nearly 50% are Hispanic or Latino, and more than 25% speak Spanish as their primary language. And for residents living outside of Ontario, where all of Malheur County’s behavioral health clinics are located, patients may have to drive more than three hours to access a clinic.
Inadequate Response
The federal government has taken some steps to offset these impacts — though economists and health care researchers suggest that the measures made to date will almost certainly be inadequate.
In addition to sweeping Medicaid cuts, the OBBBA established the Rural Health Transformation Program (RHTP), which sought to distribute special funding to rural areas, like Malheur County, to offset the disproportionately high impacts that other portions of the bill would cause in regions already facing worse health outcomes. Oregon’s rural residents have been shown to “experience higher rates of chronic disease, including heart disease, diabetes and cancer,” said Clare Pierce-Wrobel, Oregon Health Authority (OHA) Director of Health Policy and Analytics, in an interview for KEZI earlier this year. The state was awarded $200 million in RHTP funding.
Across the country, the RHTP has allocated $50 billion to rural hospitals over five years — though the Kaiser Family Foundation, a national nonprofit focused on health policy, wrote in a study published in July 2025 that “Federal Medicaid spending in rural areas is estimated to decline by $137 billion, more than the $50 billion appropriated for the rural health fund.” Because of this, an estimated 338 rural hospitals are expected to close, including three in Idaho and four in Oregon — as well as additional closures among private and specialty clinics located outside of hospitals. By the end of 2025, Oregon had already lost an acute care hospital, an inpatient care center, a birth center, six occupational health centers, and four occupational medicine clinics.
In April, the first $21.7 million in RHT