ABOUT 30,000 LAWFULLY present immigrants in Massachusetts lost their subsidized health coverage through the state insurance exchange on January 1, as a result of President Trump’s big 2025 tax and spending bill, and the state has yet to offer them a bridge. That’s one of the more worrying gaps that Victoria Pulos, a senior health law attorney at the Massachusetts Law Reform Institute, sees in an otherwise aggressive state response to sweeping federal cuts to Medicaid and marketplace insurance programs.

Pulos joined John McDonough of the Harvard TH Chan School of Public Health and Paul Hattis of the Lown Institute on the monthly Health or Consequences episode of The Codcast.

The federal law enacted last July, which Trump dubbed the One Big Beautiful Bill Act, is “this latest and perhaps the greatest challenge” to Medicaid and the state Connector Care program, Pulos said. The state estimates the law will cost Massachusetts $3.5 billion a year in lost federal revenue once fully implemented, and could leave 300,000 residents uninsured.

“It wreaked havoc,” Pulos said.

She noted that there are efforts to use Medicaid data to aid ICE enforcement, among the pile of administrative and regulatory changes packed into the bill. The administration contends that the changes are aimed at cracking down on fraud, waste, and abuse.

Pulos zeroed in on how the bill narrowed immigrant eligibility for both Medicaid and marketplace coverage to just three categories: lawful permanent residents, certain Cubans and Haitians with particular immigration statuses, and residents from the Marshall Islands, Palau, and Micronesia — a small population in Massachusetts.

The Connector Care program — a state exchange where individuals can buy insurance, including with subsidies for those with lower income – had previously covered a broad range of lawfully present immigrants with work authorization.

A second wave hits in October, when an estimated 2,500 MassHealth enrollees — refugees, asylum recipients, trafficking victims, domestic violence survivors — lose federal Medicaid eligibility.

On the Connector Care side, Massachusetts is in better shape than most states on premium affordability. When enhanced federal tax credits expired at the end of 2025, the Connector drew on a trust fund to make up $250 million of the difference.

Work requirements are the other looming deadline. Starting January 1, the roughly 300,000 to 360,000 adults enrolled in MassHealth Care Plus — the state’s Medicaid expansion program — will have to demonstrate 80 hours per month of work, community service, job training, or half-time school enrollment, or qualify for an exemption. The state plans to use claims data to automatically identify people who meet exemptions, sparing some the paperwork burden. But key federal guidance is still pending, and Pulos said execution is uncertain.

“The state has not always been good in its IT system changes, its training, its customer service,” she said.

The same population faces more frequent eligibility renewals — every six months instead of annually. “Every time that happens, a lot of people drop off just because they can’t handle the paperwork,” Pulos said.

On the state’s overall response, Pulos gave mixed marks. She credited the Healey administration and Legislature for signaling they want to minimize coverage losses, including funding an outreach campaign modeled on the post-pandemic Medicaid unwinding effort. But she was pointed about the immigrant coverage gap.

“The Connector Authority, the connector board, the connector staff — they’re fabulous, but they have not come up with a solution. They have not stepped up, nor has the governor, the state, the Legislature,” she said. “That would not be a passing grade in my book as yet, but there’s still time.”

On the episode, Hattis, McDonough, and Pulos discuss the federal law and its consequences for MassHealth and the Connector (2:15), what the state can do to limit coverage losses (10:30), and immigrant insurance eligibility cuts (12:00).