State-Directed Payment caps and provider tax reductions under OBBBA will cut hospital Medicaid revenues by over 20% in multiple states starting in 2028. The risk of escalating uncompensated care is growing significantly. OBBBA introduces mandatory 80-hour monthly work requirements and 6-month redetermination cycles for expansion enrollees. OBBBA caps SDP rates to 100% of Medicare in expansion states (110% in non-expansion states) starting in 2028, ending previous caps tied to higher commercial averages. “Loss of federal funding and growth in uncompensated care coupled with inflation and labor force problems will raise costs and reduce revenue.”