AFTER MONTHS of nationwide uncertainty over looming threats to Medicaid, a clearer — but still murky — road now lies ahead for public health leaders across the Commonwealth. Over 300,000 Massachusetts residents — nearly 5 percent of the state’s population — are expected to lose Medicaid coverage by 2034 under the One Big Beautiful Bill Act.

The sweeping changes will likely hit hardest the state’s Gateway Cities, which are home to a disproportionate share of the state’s immigrants and low-income population, as work requirements and eligibility checks ramp up. During a 2023 Medicaid enrollment purge, MassHealth — the state’s Medicaid and Children’s Health Insurance Program — identified 15 “priority communities” that officials believed had the most residents at risk of losing coverage — 13 of which were Gateway Cities.

Some Gateway City leaders say they expect to take on the burden of educating enrollees, keeping them insured under new requirements, and helping disadvantaged communities navigate the approaching changes to MassHealth.

For now, these communities are doing the best they can to prepare for the thousands of residents expected to lose health coverage while they wait for more guidance from the state. Some are coordinating with their local or regional health centers and hospitals, while others are organizing targeted outreach and relying on community ties.

President Trump and Congressional Republicans’ reconciliation bill, signed into law on July 4, calls for non-disabled adult recipients under 65 to work, train, or volunteer for at least 80 hours per month starting as early as January 2027. Eligibility checks will be required every six months instead of yearly. Many immigrants with legal status will no longer be eligible, including refugees, people granted asylum, and certain abused spouses, children, and trafficking victims.

“We are being forced to do things that really shouldn’t fall on local government,” said Chelsea City Manager Fidel Maltez. “We are terrified, because we have seen it time and time again. When the federal government does not step in, residents show up at our doorstep. They ask for help, and we’re in the front lines.”

Elvira Pinjic, executive director of the Joint Committee for Children’s Healthcare in Everett, runs a team of certified health insurance navigators that operates rent-free out of Everett City Hall and works closely with the city to provide education and assistance to low-income residents. Nearly 47 percent of the city is foreign-born, which is significantly higher than the state average of 18 percent. More than 15 percent of residents had an income below the poverty level in 2023.

Requiring enrollees to re-up their eligibility twice a year means “double the work,” Pinjic said. Once they receive more guidance from the state on what kinds of paperwork will be required, the team plans to use their database to reach out to MassHealth enrollees via WhatsApp, social media, and other avenues to answer questions, offer help, and send reminders. They are also partnering with churches throughout the city to spread the word about significant changes to MassHealth.

“You would go to your city hall first, before you go anywhere else,” Pinjic said. “They’re not going to go to the state … they will come to us to ask these questions.”

Work and reporting requirements have been shown to confuse enrollees and have resulted in eligible members losing their coverage due to paperwork problems. (For example, more than 18,000 adults in Arkansas lost coverage after the state established a work reporting requirement in 2018 that lasted just 10 months.) Most adults on Medicaid under the age of 65 are working full or part-time already, unless they are inhibited by school, caregiving responsibilities, illness or disability, according to KFF, a nonprofit health policy research and polling organization.

“The most marginalized are the ones who are not going to be able to do this,” said Dr. Mattie Castiel, Worcester’s commissioner of health and human services. “I can’t tell you how many people just forget to re-up their MassHealth. They’re not going to meet those requirements.”

Between April 2023 and 2024, around 362,000 people were dropped from MassHealth in a period of post-pandemic eligibility redetermination. Two-thirds lost their coverage due to providing insufficient information, according to the Executive Office of Health and Human Services.

Worcester City Hall now serves as an “unlocked front door” for those with questions about coverage, according to Castiel, and they plan to conduct more outreach by bringing information directly into the communities that will be most affected. They often rely on local philanthropic organizations to do this work, but that help can only go so far. “Everybody’s going to be knocking at the same door.”

Nearly 21 percent of Worcester residents had an income below the poverty level in 2023, and over 23 percent of residents were born outside of the country. Staff and residents alike “feel that stress and anxiety about what’s next,” Castiel said.

Beginning Jan. 1, 2026, low-income immigrants in the five-year waiting period before they can qualify for Medicaid will no longer be eligible for tax credits and cost-sharing reductions when buying health insurance on the Affordable Care Act’s Health Insurance Marketplace.

“Given our proximity to the people we serve, we are often dealing with the fallout of these decisions that are made at the federal level,” said Mayor Jared Nicholson of Lynn, who added that communication barriers are a major concern throughout the city, where over 40 languages are spoken and nearly 36 percent of residents are foreign born.

For now, the city is relying on the Lynn Community Health Center, which operates school-based services that remain their main touchpoint with children enrolled in Medicaid.

City officials in Malden have similar fears. Around 70 languages are spoken in its public schools, and more than 41 percent of the population is foreign born. Educating residents will be their biggest challenge.

The federal tax bill will cut an estimated $1.75 billion from the Massachusetts health care system, according to Gov. Maura Healey’s administration. Municipalities are reimbursed for Medicaid expenses, particularly through the School-Based Medicaid Program and other qualifying services.

In Fitchburg, Mayor Sam Squailia says this funds a portion of their budget, and the city may have to cut services or raise taxes to offset the loss of those reimbursements.

“We’re just hoping not to instill fear and panic in the community,” Pinjic said. “We are yet to learn what the state of Massachusetts is actually going to do.”