As states and health systems prepare for sweeping changes to Medicaid under legislation that passed last year, including new mandatory "community engagement" (work, education, training and related activities) for many adults outlined in H.R. 1, Catholic health care leaders have a distinctive lens to bring to implementation: the moral vision articulated in Pope Leo XIV's 2025 apostolic exhortation Dilexi Te (I Have Loved You).1
Grounded in love for the poor and continuity with Catholic social teaching, Dilexi Te offers practical, ethical guardrails for how we approach policy shifts that risk increasing barriers to care for vulnerable populations. Catholic health care ministries have a unique responsibility and opportunity to meet this critical moment, as states begin implementing these new policies in partnership with the Centers for Medicare and Medicaid Services (CMS).
WHAT IS DILEXI TE?
Pope Leo issued this writing as an apostolic exhortation, which means that he is urging the faithful to heed a conclusion or insight, and to seriously ponder the points made in the document. The document's style is akin to a chief executive telling the organization's leaders that a unified focus needs to be given to this matter.2
The theme of Dilexi Te is love and care for the poor. Pope Leo is drawing from his own experience in this document. Though born and educated in the U.S., he spent more than two decades in South America, the latter part serving as Bishop of Chiclayo, Peru, working largely with poor and indigenous communities. His ministry in Peru convinced him of the penetrating truth in the Church's teaching on the preferential option for the poor.
As is said, if you want to know or experience God, spend time with those who are poor. This is because all throughout the scriptures, God appears among and remains close to the poor, and they are most often the faithful ones. Those who are poor may not have access to other means, people or efforts to advocate for them. The poor are not just the financially poor. With little influence or access to power structures, poor people are in a precarious position, and decisions that may not be of great consequence for others can be life or death for those without resources. All they may have left is to trust in God's fidelity, love and providence. This explains a connection between Pope Leo's first major teaching and the work of Medicaid.
WHAT CHANGED IN MEDICAID WITH H.R. 1?
H.R. 1 (the "One Big Beautiful Bill Act" or the "Working Families Tax Cut Act") introduces nationwide community engagement requirements for certain Medicaid enrollees. Adults ages 19-64 in Affordable Care Act expansion groups must document at least 80 hours per month of work, education, a qualifying work program, community service or meet minimum income thresholds by late 2026 and early 2027 timelines; states must also conduct semiannual eligibility redeterminations for expansion groups.3 CMS issued initial guidance on how states should implement new work requirements for Medicaid enrollees in December 2025, and is required to publish an interim final rule by mid-2026.4
We don't have to look too far to see how these new policies could affect people's access to Medicaid. Arkansas' experience with Medicaid work requirements offers a cautionary tale for federal policy. In its 2018-2019 pilot, adults aged 30-49 were required to document 20 hours of work, job training or volunteering weekly. Within just seven months, roughly 18,000 individuals — about 1 in 4 subject to the policy — lost coverage, and very few regained it the following year.
A comprehensive analysis published in Health Affairs confirmed significant coverage declines in Arkansas compared with neighboring states, without any improvement in employment trends.5 Arkansas' Medicaid work requirement program was halted in April 2019 after a federal court ruled that the policy failed to align with Medicaid's core purpose of providing health coverage.
These findings underscore how administrative hurdles — not health status or work ability — can drive disenrollment, disproportionately harming low-income residents lacking stable housing, reliable transportation or digital access.
WHAT IS CATHOLIC HEALTH CARE'S ROLE?
Catholic hospitals, clinics and health systems have unmatched reach and trust in communities, making them essential partners in minimizing coverage loss under new Medicaid engagement rules. Drawing on lessons from the Medicaid unwinding of its continuous coverage provision after the COVID-19 Public Health Emergency, and CHA's response to help aid enrollment and retention through its "Protect What's Precious: Secure Your Medicaid Coverage Today" initiative, Catholic health care knows that proactive outreach, simplified processes and trusted community partnerships are essential to prevent eligible individuals from losing coverage due to paperwork barriers.
By collaborating with CMS, state health agencies and local organizations, Catholic health care can transform compliance into accompaniment, helping patients navigate Medicaid requirements while safeguarding access to care. Here is a checklist for action that we recommend:
- Partner with CMS and state agencies to shape implementation guidance that prioritizes simplicity, grace periods and good-faith exemptions.
- Deploy patient navigators and financial counselors in hospitals and clinics to assist with reporting and exemption documentation.
- Integrate workforce and education resources into care settings, offering qualifying community engagement opportunities.
- Mobilize parish, Catholic charities, human services organizations and other community networks for outreach and education in multiple languages and formats.
- Advocate for data transparency and monitor disenrollment trends to identify and address inequities quickly.
- Provide feedback to policymakers during CMS rulemaking to ensure policies align with Catholic health's mission of ensuring access to health care. CHA will continue to populate our "Medicaid Makes It Possible" microsite with resources.
- Continue to educate your colleagues, associates and communities on new guidance or changes from CMS or your state health agencies as this new policy is implemented this year.
A MINISTRY MOMENT TO LEAVE NO ONE BEHIND
Dilexi Te reminds us that love for Christ is inseparable from love for the poor. Catholic health care is not just a provider; it is a ministry of the Church. The Church is the living presence of Christ Jesus, and we must act and respond in such a way that authentically shows his mercy to the afflicted and his work to bring justice to the structures of injustice.
In the face of policy shifts that could marginalize those with "but little power," Catholic executives, board members and sponsors can embody mercy, safeguard access and transform engagement requirements into opportunities for holistic well-being. Rooted in a tradition of justice and compassion, our mission equips us to lead boldly in shaping Medicaid's future so that no one is left behind by policy or paperwork.
PAULO G. PONTEMAYOR is senior director of government relations for the Catholic Health Association, Washington, D.C.
NOTES- Pope Leo XIV, "Dilexi Te," The Holy See, https://www.vatican.va/content/leo-xiv/en/apost_exhortations/documents/20251004-dilexi-te.html.
- Valerie Schremp Hahn, "Q and A: CHA's Darren Henson Explores What Pope Leo's Dilexi Te Means for Those in Catholic Health Care," Catholic Health World, October 21, 2025, https://www.chausa.org/news-and-publications/publications/catholic-health-world/archives/october-2025/q-and-a--chas-darren-henson-explores-what-pope-leos-dilexi-te-means-for-those-in-catholic-health-a.
- These requirements also refer to adult coverage through Medicaid Section 1115 demonstration waivers, which provide benefits to certain adults who would not normally be eligible for Medicaid under federal law.
- "Working Families Tax Cut Legislation," Medicaid.gov, https://www.medicaid.gov/resources-for-states/working-families-tax-cut-legislation.
- Benjamin D. Sommers et al., "Medicaid Work Requirements in Arkansas: Two-Year Impacts on Coverage, Employment, and Affordability of Care," Health Affairs 39, no. 9 (2020): https://doi.org/10.1377/hlthaff.2020.00538.