The House voted to send it to President Donald Trump’s desk on Thursday, and the Tax and Expense Act, which enacted the majority of the domestic agenda, will cut federal health spending by about $1 trillion over the decade, in a way that puts the physical and financial health of millions of Americans.
The bill is expected to pass without a single democratic vote in both the House and Senate, reversing many of the Biden and Obama administrations’ health insurance increases. Their policies have made healthcare accessible to millions and have lowered US uninsured rates, but Republicans say the trade-offs are taxpayers burdened and the rise in fraud is much higher costs.
According to estimates from the Congressional Budget Office, Trump will be able to have around 12 million people uninsured by 2034 thanks to reduced federal support for Medicaid and the Affordable Care Act market. It is expected to undermine the finances of hospitals, nursing homes and community health centers. Some people cut down on services and employees or close them completely.
Below are five ways that GOP planning can affect access to healthcare.
Do you need Medicaid? After that, get a job
The deepest reductions in healthcare costs come from the proposed Medicaid work requirements. This is expected to close coverage for millions of enrollees who do not meet new employment or reporting standards.
As 40 states and Washington, DC are all expanding Medicaid under the Affordable Care Act, some Medicaid enrollees must regularly submit documents certifying that they have attended school at least 80 hours for school, or are eligible for exemptions such as caring for young children. The new requirements will begin early in January 2027.
The bill’s requirements do not apply to people in 10 primarily GOP-led states that have not expanded Medicaid to adults with no disabilities.
Health researchers say the policy has little impact on employment. According to KFF, a nonprofit organization that includes KFF Health News, most working-age Medicaid enrollees who do not receive disability benefits and are unable to do so because they are already seeking work, or have a disability, attending school, or are caring for a family member.
State experiments with work requirements suffer from administrative issues, including losing coverage of paperwork issues for eligible enrollees. Officially launched in July 2023, Georgia’s labor requirements cost more than $90 million, of which only $26 million has been spent on health benefits.
“The hidden costs are astronomical,” said Chima Ndumere, a professor at Yale School of Public Health.
Low cash means less care in rural communities
State-targeted belt stitting could potentially be converted to fewer health services, health professionals and even hospitals, especially in rural communities.
Follow Tampa Bay’s top headlines
Subscribe to our free Daystarter newsletter
We provide you with the latest news and information you need to know every morning.
You’re all signed up!
Want more free weekly newsletters in your inbox? Let’s get started.
Check out all options
The GOP plan has been used for decades to reduce the practice known as provider taxes and increase Medicaid payments to hospitals, nursing homes, other providers, and private managed care companies.
States often use federal funds generated through taxes to pay institutions more than Medicaid pays. Medicaid generally pays lower fees than Medicare, programs for people over the age of 65 and for those with disabilities, and private insurance. However, according to the Commonwealth Fund, a nonprofit in medical research, some hospitals are paid under Medicaid rather than Medicare, thanks to provider taxes.
Hospitals and nursing homes say they will use these additional Medicaid dollars to expand or add new services and improve care for all patients.
Rural hospitals usually operate at thin profit margins and rely on payments from Medicaid tax to maintain them. Researchers at the Cecil G. Shep Center, who investigated the original house version of the bill, concluded that they would push more than 300 rural hospitals (Kentucky, Louisiana, California and Oklahoma) towards reducing or closing services.
Senate Republicans have incorporated $50 billion into the law to ease the blow to rural hospitals. Money will be distributed from 2027 and lasts for five years.
Difficult to obtain and maintain ACA coverage
For those with Obamacare plans, the new law will make it difficult to maintain registration and compensation.
Instead of being allowed to re-register automatically, policyholders on the ACA Marketplace must update their income, immigration status and other information each year. You will also be less time to register. The bill shortens the annual open enrollment period in about a month.
People who apply for coverage outside of that period – for example, because they lose jobs and other insurance, or because they need to add newborns and spouses to their existing policies – should wait for all documents to be processed before receiving government subsidies to support monthly premiums. Today, they get up to 90 days of premium help during the application process, which can take several weeks.
Several conservative policy think tanks, including Republican lawmakers and the Paragon Health Institute, say changes are needed to reduce fraudulent registrations, but the enemy says they represent Trump’s best efforts to bring Obamacare back to normal.
The law does not require an extension of the more generous premium subsidies introduced during Covid Pandemic. If Congress doesn’t act, these enhanced subsidies will expire at the end of the year, earning premiums that will increase by 75% next year, according to KFF.
About Medicaid? Pay more to meet your doctor
Many Medicaid subscribers can expect to pay more out-of-pocket for bookings.
Trump’s law requires a state with an expanded Medicaid charge for subscribers up to $35 for some services if income is between federal poverty levels ($15,650 for individuals this year) and 138% of that amount ($21,597).
Medicaid enrollees often don’t pay anything when they ask for medical services. Because research has encouraged low-income people to refrain from the care they need by charging even small out-of-pocket expenses. In recent years, some states have added fees under $10 for certain services.
This policy does not apply to people seeking primary care, mental health care, or substance abuse treatment. The bill allows states to enact even higher cost sharing for enrollees seeking emergency room care for non-emergency situations. However, if a Medicaid patient fails to pay, the hospital and other providers can remain on the bill.
Legally presented immigration reductions
The GOP plan could result in at least hundreds of thousands of legally present migrants, including asylum seekers, trafficking victims and refugees, losing coverage in the ACA market by reducing subsidies that make premiums affordable. The restrictions do not apply to green card holders.
According to California, Maryland, Massachusetts, and health analysts, migrants who lose subsidies under the law tend to be younger than the US population, so older market enrollees push market premiums even further.
John Slotkam, executive director of the advocacy group Refugee Council USA, said in a statement.
The bill reflects the Trump administration’s restrictive approach to immigration. But because it violated Senate rules, the law does not include proposals to reduce federal Medicaid payments to states such as California, which use their money to cover immigrants without legal status.
***
KFF Health News is a national newsroom that produces detailed journalism on health issues. Along with policy analysis and voting, KFF Health News is one of KFF’s three major operating programs. KFF is a donated non-profit organization that provides the country with information on health issues.
