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Congress passed a major overhaul to America’s healthcare safety net in 2025. The “One Big Beautiful Bill Act” passed the House on July 3, 2025, by a vote of 218-214 following a Senate vote of 51-50 with Vice President J.D. Vance casting the tie-breaking vote two days earlier. The bill was signed into law by President Trump on July 4, 2025.
The 940-page law makes significant changes how Medicare and Medicaid work, affecting more than 130 million Americans who rely on these programs. Supporters and critics disagree about the bill’s effects.
What the Law Claims vs. What It Actually Does
The White House described the law as a way to cut waste, secure borders, and create a “Blue-Collar BOOM” through tax cuts and improved spending. Administration officials said it would reduce the deficit by eliminating fraud and abuse in government programs.
Budget analysts project different outcomes.
The Congressional Budget Office projects the law will add $3.3 trillion to the national deficit over the next decade. The math is straightforward: $4.5 trillion in tax cuts minus $1.2 trillion in spending cuts equals a massive hole in the federal budget.
The biggest spending cuts target Medicaid and food stamps – programs that serve low-income Americans. The CBO estimates these changes will cause 11.8 million people to lose their health insurance by 2034.
The different assessments come from budget accounting approaches. The CBO uses standard budget rules that treat extending temporary tax cuts as new spending. The law’s supporters use different accounting methods – they treat the 2017 tax cuts as already permanent, making the extensions appear cost-neutral.
The Medicaid Overhaul: $1 Trillion in Cuts
The law makes the most dramatic changes to Medicaid since the program started in the 1960s. The cuts total more than $1 trillion over 10 years – the largest reduction in the program’s history.
Here’s what changes:
| What Changes | Impact | People Affected |
|---|---|---|
| Work requirements | Must work 80 hours/month to keep coverage | CBO projects 4.8 million lose coverage |
| Stricter state financing rules | States can’t use provider taxes to fund Medicaid | $340 billion in cuts |
| More frequent eligibility checks | Coverage reviewed every 6 months instead of yearly | Part of 7.8 million total projected loss |
| Higher copayments | Up to $35 per doctor visit for some patients | May create barriers to care |
The New Work Requirement
The biggest change requires most adults under 65 who receive Medicaid through ACA expansion to work, train, or volunteer for at least 80 hours per month. Those who don’t meet the requirement lose health coverage.
Supporters say this restores the “dignity of work” and reduces enrollment of those who choose not to work. However, when Arkansas tried a similar rule, thousands of people lost coverage due to paperwork problems and reporting errors – not because they stopped working.
The policy particularly affects the 2.6 million adults with disabilities who receive Medicaid but don’t qualify for federal disability benefits. These people often can’t work consistently due to health problems, but they’re not automatically exempt from the work requirement.
Making It Harder to Get and Keep Coverage
The law creates several new administrative hurdles:
More paperwork, more often: States must now check eligibility for Medicaid expansion adults every six months instead of yearly. This doubles the chances someone could lose coverage for missing a form or not updating their address.
Stricter verification: The law eliminates “provisional eligibility,” which allowed people to receive temporary coverage while their paperwork was processed. Now, eligible families – including parents of newborns waiting for Social Security numbers – could go without insurance for weeks or months.
Higher costs: States can now charge copayments up to $35 per doctor visit for Medicaid patients with incomes above the poverty line. For families living on low incomes, these costs can prevent people from getting necessary medical care.
The State Budget Crisis
The law significantly restricts how states pay for their share of Medicaid costs. States have long used provider taxes and special payment arrangements to fund their portion of the program. The new law limits these financing tools, effectively shifting hundreds of billions in costs to state budgets.
States will face an difficult choices: raise taxes, cut other services like education and roads, or make even deeper cuts to their Medicaid programs.
Rural Hospitals in Crisis
Rural hospitals face a perfect storm under the new law. They’re heavily dependent on Medicaid revenue and serve as the economic backbone of their communities. The American Hospital Association projects that rural hospitals will lose $50.4 billion in federal Medicaid funding over ten years, while 1.8 million rural residents will lose their coverage.
This creates a challenging cycle: hospitals receive less money from Medicaid cuts, then face a surge in uncompensated care when newly uninsured patients show up at emergency rooms.
The law includes a $50 billion “Rural Health Transformation Program” spread over five years. Critics argue this funding is insufficient to address the issue of uncompensated care and doesn’t provide sustainable long-term funding.
Medicare Changes: Higher Costs, Fewer Benefits
While Medicaid bears the brunt of the cuts, Medicare faces significant changes that will increase costs for low-income beneficiaries and restrict eligibility for certain immigrants.
Limiting Assistance for Low-Income Seniors
The law places a moratorium on a federal rule designed to help more low-income seniors get assistance with Medicare costs. Medicare Savings Programs use Medicaid funds to help pay for Medicare premiums, deductibles, and other out-of-pocket costs.
The blocked rule would have simplified applications and automatically enrolled more eligible people. By preventing these improvements, the law means that 1.3 million people who qualify for help won’t get it.
The Center for American Progress estimates that an older couple with an annual income of just $21,000 could face up to $8,340 in additional health care costs per year.
Immigrants Lose Coverage Despite Paying In
The law strips Medicare eligibility from certain groups of legal immigrants, even if they’ve worked and paid Medicare taxes for decades. This affects people with Temporary Protected Status, refugees, and asylum seekers who haven’t yet obtained green cards.
The Center for Medicare Advocacy calls this unprecedented – the first time Congress has removed Medicare eligibility for entire groups of people who have lawfully paid into the program.
The $500 Billion Sequestration Issue
The law’s massive deficit increase triggers automatic spending cuts under budget rules designed to control federal spending. Unless a future Congress acts, Medicare faces approximately $500 billion in cuts between 2026 and 2034.
This creates a significant challenge that could affect the long-term stability of Medicare and the care it provides to over 65 million Americans.
Who Is Most Affected
The law’s impacts fall disproportionately on the most vulnerable Americans:
The ‘Dually Eligible’
About 13 million Americans qualify for both Medicare and Medicaid. These are typically older adults or people with disabilities who have very low incomes. They face a double impact: Medicaid cuts reduce help with daily living and cost-sharing, while Medicare becomes more expensive and harder to access.
Children and Families
The administrative barriers and funding cuts also apply to the Children’s Health Insurance Program (CHIP). Together with Medicaid, these programs cover nearly 80 million Americans, including 38 million children. The new requirements put millions of children’s health coverage at risk.
People with Disabilities
Beyond the work requirements, the law affects home and community-based services that allow seniors and people with disabilities to live independently rather than in nursing homes. When states face budget cuts, they typically reduce these “optional” services first.
This could force many people to give up their independence and move to more expensive institutional care, raising questions about compliance with the Americans with Disabilities Act.
Rural Communities
Rural areas face a cascade of problems: hospital closures, more uninsured residents, and reduced access to care. The temporary rural health fund doesn’t address the fundamental problem of uncompensated care when millions lose insurance.
The Broader Health Care System Impact
The law’s effects extend far beyond individual coverage losses:
Provider Instability
Hospitals and clinics that serve large numbers of Medicaid patients will face significant financial pressure. The combination of direct funding cuts and increased uncompensated care could force service reductions, staff layoffs, and facility closures.
AI-Driven Prior Authorization
While not part of the law itself, the Centers for Medicare & Medicaid Services is launching the “Wasteful and Inappropriate Service Reduction” (WISeR) Model. This program uses artificial intelligence and private companies to manage prior authorization requests for Medicare services.
Critics worry this could create new, automated barriers to necessary care, with algorithms making decisions about medical treatment.
Emergency Room Surge
When people lose insurance, they don’t stop getting sick. They delay care until problems become emergencies, then show up at hospital emergency rooms that are legally required to provide stabilizing treatment regardless of ability to pay.
This creates a difficult cycle: more uninsured patients mean more uncompensated care, which puts additional financial pressure on hospitals already facing Medicaid cuts.
The Numbers Behind the Coverage Loss
The Congressional Budget Office breaks down how 16 million Americans will lose coverage by 2034:
| Source of Coverage Loss | Number of People |
|---|---|
| Medicaid changes in the law | 7.8 million |
| ACA marketplace changes | 3.1 million |
| Program integrity rule | 0.9 million |
| Expiration of enhanced ACA tax credits | 4.2 million |
| Total newly uninsured | 16.0 million |
The Medicaid Breakdown
Of the 7.8 million people projected to lose Medicaid coverage:
- 4.8 million are projected to lose coverage due to work requirements.
- The remainder are projected to lose coverage due to increased administrative barriers, more frequent eligibility checks, and state financing restrictions.
The Medicare Savings Program Impact
The 1.3 million people who won’t get help with Medicare costs represents money directly out of seniors’ pockets. These aren’t abstract budget numbers – they’re real families choosing between medications and groceries.
State-by-State Variations
The law’s impact will vary dramatically by state, depending on several factors:
Medicaid Expansion States
The 40 states that expanded Medicaid under the Affordable Care Act will see the biggest coverage losses from work requirements. These states will also face the largest budget pressures from the financing restrictions.
Nonexpansion States
The 10 states that didn’t expand Medicaid will see smaller direct coverage losses but will still face budget pressures from the financing changes affecting traditional Medicaid.
Rural vs. Urban
Rural states with large geographic areas and fewer health care providers will face additional challenges. The loss of rural hospitals could create health care deserts where people must travel hours for basic medical care.
The Political Process
The law passed through budget reconciliation, which requires only a simple majority in the Senate. This allowed Republicans to bypass the 60-vote filibuster threshold that normally requires bipartisan support for major legislation.
The narrow passage – 218-214 in the House and 51-50 in the Senate with the Vice President’s tie-breaking vote – reflects the controversial nature of the changes. No Democratic lawmakers supported the final bill.
The Rural Funding
The inclusion of the $50 billion Rural Health Transformation Program appears designed to secure votes from lawmakers representing rural districts. However, the temporary nature of the funding and its scale compared to the overall cuts suggest critics view it as more political compromise than substantive policy.
Looking Ahead: Implementation Challenges
The law’s implementation will unfold over several years, with different provisions taking effect at different times:
Immediate Effects
Some changes take effect immediately, including the moratorium on Medicare Savings Program improvements and the stricter verification requirements for ACA coverage.
Gradual Rollouts
States will need time to implement work requirements and new eligibility systems. The administrative complexity means some changes may take months or years to fully implement.
The 2026 Cliff
The automatic Medicare cuts triggered by the law’s deficit impact are scheduled to begin in 2026. This creates pressure for future Congresses to either find offsetting savings or waive the budget rules.
The Unprecedented Scale
Health care policy experts say the law represents the most significant rollback of the social safety net since the 1990s welfare reform. The combination of Medicaid cuts, Medicare changes, and ACA modifications touches virtually every aspect of American health care.
The $1 trillion in Medicaid cuts alone exceeds the entire annual budget of most federal agencies. The 16 million people projected to lose coverage represents more than the population of Pennsylvania.
For context, the Affordable Care Act, when it was fully implemented, reduced the number of uninsured Americans by about 20 million. This law is projected to move in the opposite direction, increasing the uninsured population by 16 million.
The law’s supporters argue that these changes will reduce waste and fraud while promoting personal responsibility. Critics contend that the changes will harm the most vulnerable Americans while providing tax breaks for the wealthy.
What’s certain is that the law represents a fundamental shift in how America provides health care to its most vulnerable citizens. The full impact won’t be known for years, but the Congressional Budget Office’s projections suggest the consequences will be measured in millions of lives affected and trillions of dollars in economic impact.
The debate over the law’s effects continues, but the immediate reality is that America’s healthcare safety net just underwent major changes that will affect costs and coverage for those who need it most.
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