Congress’ newly enacted One Big Beautiful Bill Act (OBBA) introduces work requirements, caps on state-directed payments and other measures that will slash roughly $1 trillion from Medicaid over ten years, leaving millions more patients potentially uninsured or under-insured according to the American Hospital Association.
While this has generated headlines, coverage churn is not new. State “Medicaid unwinding” began in April 2023 when unenrollments and reverification that had been suspended due to the Covid pandemic were lifted, and people fell off the rolls more quickly than they would have historically. This has already led to approximately 25 million disenrollments.
Ensemble has long treated under-insurance as a perpetual and complex challenge, not a one-off crisis. The same end-to-end operating model we deployed for the Medicaid unwinding easily scales to the OBBA era — protecting hospital revenue, safeguarding patient coverage and continuing to deliver a consumer-grade experience.
Why the industry is buzzing about OBBA
OBBA will bring significant impacts in the near future, including:
- Medicaid cuts + work requirements: OBBA introduces nationwide work verification and tightens eligibility redeterminations. States that exceed the 3% limit on eligibility errors face fiscal penalties such as a reduction in matching federal funds.
- Provider payment constraints: New caps on supplemental payments and limits on provider taxes intensify margin pressure for safety-net hospitals.
- Timeline shock: Major provisions phase in beginning January 1, 2026, giving hospitals less than 18 months to prepare before these provisions are effective.
OBBA magnifies an already-underway shift from insured to self-pay. Success hinges on proactively qualifying patients for coverage and crafting frictionless payment pathways.
Coverage + conversations at every step
At Ensemble, we provide always-on management of uninsured and underinsured populations , another benefit of our end-to-end approach. Our interactions with patients at every stage enable us to have a greater impact and to keep sight of coverage issues throughout the entire process. By engaging with patients from scheduling all the way to post-service billing and payment, we also have the ability to handle challenges that arise at many different stages, rather than just one based on a single point solution deployment.
Our approach is:
- Comprehensive, not episodic: Our model addresses every coverage disruption (e.g., policy change, life event or data error) through continuous analytics and advocacy.
- Patient equity- and advocacy-first: Financial conversations emphasize benefits eligibility before payment collection, preserving community trust.
- Digital by default, human by design: Tailored agentic AI automation handles routine eligibility and coverage checks as well as estimate creation. Trained financial advocates intervene where human judgment and care for the patients matter most.
Ensemble’s end-to-end patient-financial flow is already ready for OBBA, continually screening for coverage and centering the patient’s experience at every step.
Pre-service auto-screening
At scheduling, every patient record runs through Ensemble’s rules engine and 200+ data feeds to check Medicaid/Marketplace eligibility, commercial coordination of benefits, local charity and a propensity-to-pay score after an estimate is generated.
Digital estimate + financial clearance information
The patient receives a consolidated packet via preferred channel (text, email, portal) containing:
- Accurate cost estimate
- Real time coverage status and gaps
- Simple task list (e-sign forms, document uploads, prompt-pay discount window)
Arrival + Point-of-Service advocacy
Fast-track check-in exists for financially cleared patients. If coverage or payment is pending, financial advocates engage pre-service. Emergency department or unscheduled inpatients get bedside assistance (where allowed by policy) to secure coverage and set up liability arrangements before discharge.
Continuous eligibility search + auto-populated applications
The platform keeps scanning for new coverage and can auto-qualify for charity. Our comprehensive database and connections not only look at Medicaid options but also COBRA, exchange plan options, local funding and special programs such as crime victim funds, searching all avenues for coverage so patients aren’t left to bear the financial burden on their own. If additional data is needed, it triggers pre-filled forms sent to the patient. They simply review and e-sign or snap photos of proofs of income/ID.
Customized payment solutions
Ensemble’s post-care outreach begins with the patient’s chosen channel (including email, text, agent or human call), then expands based on engagement analytics. Plans include:
- Prompt-pay discounts for settlement within 15 days
- Interest-free installments over a number of months, depending on the balance
- Sliding-scale terms that mirror third-party financing without the 8%-15% merchant fees that siphon revenue from our providers
Auto-reverification + compliance reminders
For benefits subject to work-verification or annual proof-of-income, Ensemble triggers reminders 30/15/5 days before lapse. Patients respond by uploading documents (camera capture in app or web), keeping coverage — and revenue — intact.
Post-cycle analytics + bad debt reclass
If coverage still isn’t found, analytics rerun eligibility logic; newly identified payers prompt rebilling, or accounts convert to presumptive charity, as appropriate, to avoid bad debt write-off.
The bottom line
OBBA may feel like the latest earthquake in health-policy land, but for Ensemble and our clients it is simply another tremor our end-to-end model was built to absorb. Our model:
- Mitigates coverage volatility: Automated screens and reverification reminders cut avoidable self-pay conversions triggered by OBBA’s new rules.
- Protects hospital margin: Direct payment plans retain every dollar, avoiding fintech “skim” and preserving goodwill.
- Elevates patient experience: One digital journey, from estimate to zero balance, reduces anxiety and boosts loyalty in an era of heightened financial sensitivity.
Continuous eligibility analytics, advocacy-centered workflows and fee-free payment flexibility keep patients covered and hospitals financially whole, no matter how the ground shifts next.
