Senate Republicans on Tuesday passed President Donald Trump’s sprawling tax and spending package, known as the “One Big Beautiful Bill,” paving the way for a major overhaul of the country’s Medicaid program. If passed by the House, which could happen before the July Fourth holiday, millions of people stand to lose their health insurance.
The number of people without health insurance in the United States nearly halved from 2013 to 2023, falling from around 14 percent to a record low of less than 8 percent, largely driven by coverage expansion under the Affordable Care Act. That rate has held relatively steady over the past few years, with around 26 million people in the US currently without health insurance.
But the Republican budget bill making its way through Congress would likely cause those numbers to surge, adding millions of people to the rolls of the uninsured. A review from the end of June by the nonpartisan Congressional Budget Office estimates cuts of nearly $1 trillion from the Medicaid program and a loss of coverage for almost 12 million Americans by 2034 under the Senate version of the bill. (The legislation could still undergo last-minute changes before being passed.)
“Cuts to federal health care spending of this magnitude are likely to have consequences for hospitals and could lead some to lay off staff, offer fewer services, or close altogether. On top of that, with nearly 12 million people projected to lose health insurance, many would have a harder time affording needed care,” says Zack Levison, a health policy expert at KFF, a nonpartisan health policy research, polling, and news organization.
The White House says the cuts will help root out “waste, fraud, and abuse in government programs to preserve and protect them for those who rely most on them.”
One of the ways the bill would restrict access to coverage is by imposing a work requirement to enroll in Medicaid, which provides health coverage for 72 million low-income and disabled Americans. There has never been a federal work requirement for people to receive Medicaid benefits—only assessments of a person’s income and disability status—and the majority of adults in the program are already working or looking for work.
Under the bill, adults would be required to work or volunteer 80 hours a month to qualify for enrollment. Disabled and pregnant individuals would qualify for exemptions, and the Senate-passed version would allow parents with children under the age of 14 to apply for exemptions. The House version would have allowed all parents of dependent children to do so.
Deborah Greenhouse, a pediatrician in South Carolina and spokesperson for the American Academy of Pediatrics, worries about parents navigating the new exemption system. “This bill will be catastrophic for children with Medicaid,” she says. It could impose bureaucratic red tape for those who do qualify for exemptions, and some parents may not be able to meet the work requirement if they have older children with special needs.
The bill would also require states to determine Medicaid eligibility redeterminations at least every six months, instead of the current annual check. It means individuals would need to reapply to the program more often to make sure they remain eligible, which could be a hurdle to non-English speakers, people with low literacy, and others.
Another way the GOP plan would limit access to coverage is by making it harder to buy health plans through the insurance marketplaces established by the Affordable Care Act. The bill shortens the open enrollment period by a month and also doesn’t allow plans to be automatically renewed. Policyholders would instead be required to update certain personal information in order to retain coverage.
In a letter to the Senate, Rick Pollack, president and CEO of the American Hospital Association, says the loss of coverage resulting from the bill “will result in additional uncompensated care for hospitals and health systems, which will affect their ability to serve all patients.”
The GOP’s plan would also limit a mechanism states use to help fund their Medicaid programs, called provider taxes, which are levied on hospitals, nursing homes, and other health care providers. Medicaid is jointly funded by the federal government and states, with the federal government paying for a certain percentage of state Medicaid expenditures. Higher provider taxes increase state Medicaid spending, which often results in increased federal reimbursement. The Paragon Institute, a conservative health think tank, has called the practice “legalized money laundering.”
The Congressional Budget Office expects that states would need to modify their Medicaid programs by taking measures such as reducing provider payment rates, reducing the scope or amount of certain health care services, and reducing Medicaid enrollment.
Jake Haselswerdt, associate professor of government and public affairs at the University of Missouri, who studies Medicaid and the Affordable Care Act, says the bill will have broad implications for the Medicaid program. “States are basically going to have to figure out other ways to pay for the things they’ve been paying for,” he says.