Despite President Donald Trump’s team claiming otherwise, experts say his One Big Beautiful Bill will have devastating effects on the health of millions. With cuts of nearly $1 trillion to Medicaid and the Affordable Care Act (ACA) over the next decade, and potential repercussions for Medicare on the horizon, the law could cause more than 16 million Americans to lose their health coverage, especially among low-income, disabled, and rural populations.
Massive cuts and new work requirements
The Congressional Budget Office (CBO) estimates that Trump’s bill will cut federal funding for Medicaid and CHIP (Children’s Health Insurance Program) by $1.02 trillion by 2034. These cuts are mainly due to new eligibility restrictions, frequent income and residency verification, and the imposition of 80-hour monthly work requirements for many adult enrollees between the ages of 19 and 64 without dependents.
This could cause at least 11.8 million people to lose Medicaid coverage. “Regardless of the precise effect, this is undoubtedly the largest regressive cut in federal health benefits ever enacted in the United States,” says health economist Dr. William H. Dow of the University of California, Berkeley. The Center for American Progress echoes this warning, noting that the cuts will hurt those who depend most on Medicaid.
Although the bill includes exemptions for people with disabilities, many could lose coverage due to bureaucracy or difficulty proving their eligibility. In Arkansas, a 2018 pilot program with similar work requirements resulted in 18,000 people losing Medicaid in seven months, mainly due to administrative hurdles rather than ineligibility.
Impact on immigrants
The law introduces several provisions that will restrict access to health coverage for immigrants, both documented and undocumented. Under the new law, the definition of who is eligible for ACA subsidies is narrowed, preventing access for thousands of refugees, asylum seekers, and immigrants with humanitarian visas.
In addition, states that provide Medicaid coverage to undocumented immigrants will face financial penalties. Therefore, this reduction in federal support is likely to pressure states to withdraw support. For example, California announced a freeze on new Medi-Cal enrollments for undocumented immigrants, and Illinois suspended a similar program due to cost concerns.
In addition, immigrants with legal status who have contributed to Medicare may lose their eligibility due to a provision that eliminates their access to the program.
These changes come despite the fact that immigrants, especially undocumented ones, are already largely excluded from most federal healthcare programs and tend to use fewer public benefits than native-born citizens.
Impact on people with disabilities and chronic illnesses
On the other hand, it is estimated that 2.6 billion adults with disabilities who do not receive Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) could be penalized by the new requirements, even though many have difficulty working due to their health condition. Experts argue that the bureaucratic burden, such as submitting monthly employment verification, could cause eligible individuals to be excluded simply because they cannot deal with the red tape.
A report by Dr. Sanjay Basu, chief medical officer at Waymark, warned that the loss of Medicaid coverage under the bill would lead to a deterioration in health services. His team’s analysis, published in JAMA Health Forum, predicts more than 1,000 additional deaths per year, nearly 100,000 hospitalizations, and $7.6 billion in new medical debt due to delayed health care. In the worst-case scenario, the number of deaths could double.
Risks for rural populations
The consequences of the legislation are likely to be most severe in rural areas, where Medicaid accounts for a large portion of hospital revenue. Although the bill includes a $50 billion “rural stabilization fund” over five years, experts say it is not enough to offset the damage that will be caused by the loss of $1 trillion in Medicaid funding. With nearly 300 rural hospitals at risk of closure and 44% operating at a loss, any revenue shortfall could cause them to disappear.
Jennifer Mensik Kennedy, president of the American Nurses Association, told ABC News that rural patients could have to drive “three or four hours to give birth or receive emergency care.” Rural residents with disabilities are especially vulnerable, as they rely more on Medicaid than their urban counterparts and have fewer alternative providers.
Medicare in jeopardy
Although the bill’s greatest direct impact is on Medicaid, Medicare could also be affected. According to the CBO, the bill could trigger automatic cuts of nearly $490 billion in Medicare between 2027 and 2034 under the 2010 Mandatory Pay-As-You-Go Act, unless Congress intervenes. Trump’s bill will also block expanded access to Medicare savings programs for low-income seniors and eliminate Medicare eligibility for some legal immigrants who have contributed to the system.
State-level responses
Some states may try to soften the blow, such as California, where funding has been provided to expand Medicaid benefits for undocumented immigrants. However, William Dow warns that budget pressures caused by the bill may force even progressive states to cut programs. California has already announced a freeze on new immigrant enrollments in Medi-Cal due to federal funding restrictions.
There are still opportunities to reverse or mitigate these changes. Many provisions will not take effect until 2027 or later, leaving room for possible legislative reversals.
