Cramer Urges Phased Medicaid Changes for North Dakota

Senator Kevin Cramer asks federal health officials to partner with North Dakota on a gradual transition to new Medicaid expansion payment rules.

Updated on Nov. 3, 2026 in Healthcare

Bold flat-color editorial illustration of stepped concrete entry blocks rising toward a low rural building on open prairie, in navy, cream, and muted red. — North Dakota Senator Kevin Cramer asked federal health officials to phase in Medicaid expansion payment changes to avoid a fiscal cliff for rural providers. AI Illustration. Upload story photo >

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North Dakota Senator Kevin Cramer sent a letter to Health and Human Services Secretary Robert Kennedy Jr. and CMS Administrator Dr. Mehmet Oz requesting a phased approach to Medicaid expansion reimbursement changes in the state. He also asked for federal collaboration on implementing the Rural Health Transformation Program there.

Why it matters

Cramer warned that without a phased transition, providers could face a fiscal cliff, and that abrupt changes could disrupt providers, patients and communities. For North Dakota, with its large rural population and long travel distances, the timing and pace of payment changes directly shape access to care.

The Rural Health Transformation Program is a $50 billion federal investment created under the Working Families Tax Cut Act. Reductions to certain Medicaid expansion state directed payments begin January 1, 2028, with rates declining annually until the target is reached.

The players

Kevin Cramer

Kevin Cramer is the U.S. Senator from North Dakota who has been a prominent voice on federal health and energy policy.

Robert Kennedy Jr.

Robert F. Kennedy Jr. is the U.S. Secretary of Health and Human Services, overseeing federal health agencies including CMS.

Mehmet Oz

Dr. Mehmet Oz is the Administrator of the Centers for Medicare & Medicaid Services, the federal agency that administers Medicaid.

The details

Cramer's letter asks federal agencies to work with North Dakota on a phased approach to changes in Medicaid expansion payments, and to partner on using the Rural Health Transformation Program to transform healthcare in the state. The legislation includes a tiered pathway to reduce certain approved state directed payments, and Cramer argued the state needs time to adjust.

January 1, 2028: Tiered reduction of certain Medicaid expansion state directed payments begins.
November 3, 2026: Cramer's letter to Kennedy and Oz is sent from Bismarck.

Health Landscape

The Working Families Tax Cut Act created the $50 billion Rural Health Transformation Program and a tiered schedule for reducing Medicaid expansion state directed payments starting in 2028. Cramer's request applies that federal framework to North Dakota's rural health system and asks for a gradual transition instead of abrupt cuts.

For North Dakota Medicaid expansion enrollees and rural providers, the pace of the 2028 payment reductions will determine whether clinics and hospitals can plan budgets and keep services open. A phased transition would give providers time to adjust, while abrupt changes could force service cuts in communities far from larger facilities.

The takeaway

Medicaid funding changes often arrive on a fixed calendar, so providers and patients in rural states benefit from watching early for phase-in schedules and federal grant opportunities. Tracking the 2028 timeline now gives local health systems more room to plan.