Key Points
- Congressional Republicans and President Donald Trump are advancing the “One Big Beautiful Bill Act,” which would roll back health coverage for millions of Americans for the first time in modern U.S. history.
- The Congressional Budget Office (CBO) estimates between 10.9 and 11.8 million Americans could lose health insurance by 2034 under the proposed legislation.
- The bill imposes new work requirements and more frequent eligibility checks for Medicaid recipients, with stricter rules than previous versions.
- A key Medicaid funding mechanism—provider taxes—faces a significant overhaul, but the Senate parliamentarian ruled core elements violate chamber rules, complicating passage.
- The bill includes $1.1 trillion in health care cuts, with over $1 trillion coming from Medicaid alone.
- Senate Republicans added a $25 billion rural hospital stabilization fund to address concerns over rural health care access.
- Sen. Bernie Sanders (I-Vt.) released a report warning the bill could nearly double the uninsured rate in some states and disproportionately impact working-class and low-income Americans.
- Public opinion is largely negative: nearly two-thirds of Americans view the bill unfavorably, and more than half worry about its impact on their ability to afford care.
- The bill faces procedural and political hurdles in the Senate after the parliamentarian’s ruling, with Democrats united in opposition.
- If enhanced ACA premium tax credits expire at the end of 2025, the number of uninsured could rise to 16 million.
In a historic first, President Donald Trump and a Republican-controlled Congress are on the verge of enacting legislation that would significantly increase the number of uninsured Americans, reversing decades of efforts to expand health coverage. The sweeping “One Big Beautiful Bill Act” targets Medicaid and the Affordable Care Act (ACA), with nonpartisan projections showing millions could lose their health insurance if the bill becomes law.
What Is the “One Big Beautiful Bill Act” and Who Will Lose Coverage?
As reported by Phil Galewitz of KFF Health News, the “One Big Beautiful Bill Act” is a budget reconciliation package that advances several of President Trump’s top priorities, including extending tax cuts that primarily benefit high-income households. The bill’s most controversial elements are deep cuts to Medicaid, new work requirements for enrollees, and changes to the ACA that would reduce federal support for coverage.
According to the Congressional Budget Office (CBO), the House-passed version would result in 10.9 million Americans losing health coverage by 2034. The Senate’s version, analyzed by Peter Sullivan of The Hill, would push that number even higher, to 11.8 million uninsured, as it includes steeper Medicaid cuts and stricter eligibility rules.
The uninsured would be predominantly low-income adults under 65 and people of color, with the highest rates in Southern and Western states that have not expanded Medicaid. The uninsured rate in non-expansion states was already nearly double that of expansion states in 2023.
How Would Medicaid and the ACA Be Changed?
Medicaid Restrictions and Work Requirements
As detailed by Kathryn Watson of CBS News, the Senate version of the bill imposes work requirements for certain able-bodied Medicaid recipients, mandating 80 hours per month of work, volunteering, or other qualifying activities. House Speaker Mike Johnson defended the measure to CBS News, calling it “moral,” and stating,
“If you are able to work and you refuse to do so, you are defrauding the system. You’re cheating the system.”
The bill also requires more frequent eligibility checks for Medicaid, making it harder for people to stay enrolled. According to the CBO, these requirements would save an estimated $325 billion over the next decade but would also result in millions losing coverage, including many who already work or cannot work due to disability.
Provider Tax Overhaul and Senate Setback
A central funding mechanism for Medicaid—the provider tax, which states use to boost their federal Medicaid funding—would be significantly reduced under the bill. Senate Republicans proposed lowering provider taxes from 6% to 3.5% by 2032, a move that would save billions but threaten the financial viability of many hospitals, especially in rural areas. However, as reported by the Associated Press, the Senate parliamentarian ruled this provision violates chamber rules, forcing GOP leaders to consider removing or amending it to move forward.
Affordable Care Act (ACA) Changes and Premium Tax Credits
The bill codifies changes from a recent Trump administration rule affecting ACA marketplaces and does not extend enhanced premium tax credits set to expire at the end of 2025. If these credits expire, out-of-pocket costs for ACA plans will rise sharply, likely causing millions more to drop coverage. The CBO estimates that the uninsured could reach 16 million if both the bill passes and the tax credits lapse.
What Are the Projected Impacts on Americans and States?
Real-Life Consequences for Patients
Phil Galewitz of KFF Health News and Sarah Jane Tribble of WGBH both highlight the story of Alton Fry, a 54-year-old self-employed contractor from rural Georgia, who was diagnosed with prostate cancer but found ACA plans unaffordable and did not qualify for Medicaid under Georgia’s limited expansion. Fry’s experience—turning to crowdfunding and forgoing recommended treatment—illustrates the financial and health risks facing millions if coverage is reduced.
Jennifer Tolbert, deputy director of KFF’s Program on Medicaid and the Uninsured, told WGBH, “The effects could be catastrophic,” warning of increased delays in care, loss of access to doctors and medications, and worsening health outcomes.
State-by-State Effects and Disproportionate Burden
Sen. Bernie Sanders, in a new report from the Senate Health, Education, Labor, and Pensions Committee, found that the bill would increase the uninsured rate in every state and nearly double it in states like Florida, Louisiana, Massachusetts, and Washington. The report also notes that for every millionaire household receiving a tax cut, 19 Americans would lose health insurance.
Why Are Republicans Pushing These Changes?
Fiscal conservatives, such as Michael Cannon of the Cato Institute, argue that the U.S. spends twice as much per capita on health care as other wealthy nations and that reforms are needed to control costs. However, Cannon told KFF Health News that the bill does not address the root causes of high costs, such as administrative complexity and the tax break for employer-sponsored insurance.
Republican leaders maintain that work requirements and spending caps are necessary to ensure the sustainability of Medicaid and reduce federal deficits, even as the bill extends tax cuts for high earners.
What Are the Political and Procedural Hurdles?
Senate Parliamentarian’s Ruling and Democratic Opposition
As reported by the Associated Press, the Senate parliamentarian’s ruling against the Medicaid provider tax overhaul is a significant setback for Republicans, who must now decide whether to amend the bill or risk losing critical votes in the closely divided Senate. Democrats are unanimously opposed, arguing the bill would devastate health care for millions.
Public Opinion and Legislative Outlook
A recent KFF poll found that nearly two-thirds of Americans view the bill unfavorably, and more than half are concerned about its impact on their family’s ability to afford care. With the Fourth of July deadline set by President Trump approaching, the outcome remains uncertain as GOP leaders scramble to secure enough support.
What Is the Future for U.S. Health Coverage?
Sen. Bernie Sanders warned that the bill would create a “national health care emergency” and a “death sentence for working-class and low-income Americans throughout the country,” citing responses from over 750 health care providers nationwide. The CBO and health policy experts agree that the legislation would mark a historic reversal in U.S. health policy, increasing the uninsured rate for the first time in the modern era.
The fate of the “One Big Beautiful Bill Act” remains uncertain as the Senate grapples with procedural challenges and public backlash. What is clear, based on bipartisan analysis and reporting from KFF Health News, WGBH, CBS News, The Hill, the Associated Press, and others, is that the legislation would have far-reaching consequences for millions of Americans, the health care system, and the nation’s social safety net.