On Tuesday, July 1, 2025, the U.S. Senate narrowly passed President Donald Trump’s sweeping tax and spending package, dubbed the “One Big Beautiful Bill,” with Vice President JD Vance casting the tie-breaking vote.
The legislation, now headed to the House for a final vote, promises significant tax cuts but includes deep reductions to Medicaid and changes to Affordable Care Act (ACA) enrollment processes that could reshape healthcare access for millions of Americans.
According to the nonpartisan Congressional Budget Office (CBO), the bill could result in nearly 12 million people losing health insurance by 2034, with broader implications for hospitals, rural communities, and low-income families.
The cornerstone of the bill’s healthcare provisions is a $1.1 trillion cut to Medicaid over the next decade, primarily targeting the program that serves low-income and disabled Americans.
The CBO estimates that 11.8 million people could lose Medicaid coverage by 2034 due to these changes, with some analysts suggesting the number could climb to 17 million when combined with expiring ACA subsidies and new regulatory hurdles.
Key changes to Medicaid include:
- Work Requirements: Starting in December 2026, able-bodied adults aged 19 to 64 without young children must work, volunteer, or attend school for at least 80 hours per month to maintain eligibility. This requirement, projected to save $325 billion over a decade, has sparked debate. While supporters argue it promotes self-sufficiency, critics note that most Medicaid recipients who can work already do, and the added paperwork could disproportionately affect vulnerable populations like non-English speakers or those with low literacy.
- Frequent Eligibility Checks: The bill mandates Medicaid eligibility redeterminations every six months instead of annually, increasing administrative burdens. Experts warn this could lead to coverage losses for eligible individuals who struggle to navigate the process.
- Provider Tax Reductions: States rely on provider taxes to fund their share of Medicaid costs. The Senate version of the bill lowers these taxes from 6% to 3.5% by 2032, potentially forcing states to reduce services, provider payments, or enrollment to balance budgets. A $50 billion rural hospital stabilization fund was added to mitigate concerns, but hospital leaders argue it’s insufficient to offset the cuts’ impact.
The White House defends these measures, stating they aim to eliminate “waste, fraud, and abuse” to preserve Medicaid for those who need it most, such as pregnant women, children, seniors, and people with disabilities.
However, experts like Edwin Park from Georgetown University argue that most provisions target coverage expansion and access rather than fraud, with only minor measures addressing actual waste, such as verifying beneficiaries’ vital status.
ACA Marketplace Changes: New Barriers to Coverage
The bill also introduces significant changes to ACA marketplaces, affecting the 24 million Americans enrolled in these plans.
Key provisions include:
- Shortened Enrollment Periods: The open enrollment period for ACA plans will be reduced from November 1 to January 15 to November 1 to December 15, potentially impacting the 40% of enrollees (approximately 10 million people) who typically sign up after mid-December.
- Elimination of Automatic Reenrollment: Over 10 million ACA enrollees were automatically reenrolled in 2025, but the bill requires annual updates to income, immigration status, and other information, starting in 2028. Policy experts like Sabrina Corlette from Georgetown University warn that these administrative hurdles could lead to coverage losses, particularly among younger, healthier, and lower-income individuals, destabilizing insurance markets and driving up premiums.
- End of Year-Round Enrollment for Low-Income Individuals: A Biden-era policy allowing those earning up to 150% of the federal poverty level (about $22,600 for an individual) to enroll in ACA plans year-round will be eliminated, further limiting access.
The CBO estimates these changes could result in 700,000 additional uninsured individuals by 2034, with broader impacts if enhanced ACA subsidies expire at the end of 2025.
The Medicaid cuts and ACA changes could have devastating effects on healthcare providers, particularly in rural areas.
Hospitals, especially those serving high proportions of Medicaid patients, face financial strain from increased uncompensated care.
Ngozi Ezike, CEO of Sinai Chicago, where 70% of patients are Medicaid recipients, warns that reduced coverage will lead to delayed care, more emergency room visits, and potentially avoidable deaths.
Rural hospitals, already operating on tight margins, are particularly vulnerable.
Jennifer Mensik Kennedy of the American Nurses Association notes that these facilities rely heavily on Medicaid revenue, and cuts could force closures, exacerbating access issues in underserved areas.
A doctor from Texas highlighted the risk to rural patients, noting that hospital closures could mean hours-long travel for critical care, potentially increasing mortality rates for conditions like strokes.
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Broader Economic and Social Implications
The bill’s healthcare cuts are part of a broader strategy to fund tax reductions, including extensions of the 2017 Tax Cuts and Jobs Act and new exemptions for tips, overtime, and auto loan interest.
However, the CBO and independent analysts estimate the bill will add $2.4 trillion to $3.8 trillion to the federal deficit over a decade, contradicting claims from White House Press Secretary Karoline Leavitt that it reduces deficits.
Critics, including Senator Bernie Sanders, argue the bill prioritizes tax breaks for the wealthy—offering an average of $400,000 annually to the top 0.1% of earners—while cutting safety nets for low-income families.
Sanders’ report, based on responses from over 750 healthcare providers, predicts a “national health care emergency,” with uninsured rates potentially doubling in states like Texas and Florida.
The bill has sparked fierce debate.
Democrats, including Senator Elizabeth Warren, have warned that it could strip health insurance from up to 16 million Americans, comparing the impact to the combined populations of several states.
Posts on X reflect public concern, with users like @RpsAgainstTrump emphasizing the bill’s deficit increase and coverage losses.
Republicans, however, argue the bill strengthens safety nets by targeting inefficiencies.
The White House claims that improper Medicaid payments, estimated at $56 billion annually, justify the reforms, though critics counter that these figures are overstated and the cuts go far beyond addressing fraud.
What’s next?
As the bill heads to the House, its passage remains uncertain due to Republican divisions over the depth of Medicaid cuts and other provisions, such as state and local tax deductions.
If passed, the legislation could mark the largest rollback of federal health coverage since the ACA’s implementation, reversing gains that reduced the uninsured rate from 14% in 2013 to under 8% in 2023.
For Americans like Alton Fry, a Georgia contractor facing prostate cancer treatment without insurance, the stakes are personal.
The bill’s changes could exacerbate challenges for the 26 million uninsured, particularly in non-expansion states where access to care is already limited.
As the July 4 deadline looms, the debate over the “One Big Beautiful Bill” underscores a fundamental tension: balancing fiscal priorities with the health and well-being of millions.
The outcome will shape the nation’s healthcare landscape for years to come.
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