Until the US passed the Affordable Care Act in 2010, being on a low income did not entitle adults to government supported health insurance. The government supported older people and children, people with disabilities, and those who were pregnant through Medicare or Medicaid. But aside from a few states having special waivers for covering a larger Medicaid population, simply being on a low income did not make a person eligible for healthcare insurance coverage. Healthcare reform had expanded access considerably, but after a new bill, H.R.1, was passed in July 2025—also known as the One Big Beautiful Bill Act—an estimated 10 million people who gained Medicaid as a result of the Affordable Care Act will now lose their coverage.1 This will harm them and the healthcare system as a whole.
The Affordable Care Act allowed states to expand Medicaid to adults on a low income without disability. Forty states opted to do this, enticed by the federal government covering 90% of the cost. This Medicaid expansion markedly decreased the number of uninsured people in the US and has been associated with improvements in access and uptake of healthcare and higher quality of care.2
The methods by which the government will decrease Medicaid coverage under H.R.1 reflect ongoing debates in the US about the role of government versus individual responsibility, as well as which people on low incomes are considered “deserving” of support.
The two provisions of H.R.1 that will result in the largest Medicaid losses do not seem too onerous at first glance. First, a work requirement with exceptions for going to school, being a new mother, being unable to work owing to health issues, or volunteering. Second, increasing the frequency of re-enrollment for Medicaid.
Work has a positive value for society and people, and allowing exceptions should, in theory, protect people who do not work in the regular economy. However, most healthy adults with Medicaid are already working in low paying jobs that do not provide health insurance. Mandating work requirements has already been tried unsuccessfully in the US. The state of Arkansas implemented an employment mandate for Medicaid and it did not result in more people working—in large part because most recipients were already working. It did, however, result in 18 000 people losing insurance coverage,3 because many people eligible for Medicaid did not successfully complete paperwork to show that they were working or exempt. Despite the data on this Arkansas experience, work requirements are heralded by some elected leaders as a way of making sure that money is not spent on “capable adults who choose not to work.”4 Work requirements are based on the idea of distinguishing those who are “worthy” of help from those who are not, and rewarding self-reliance rather than dependence on government support. But the only effect of the policy will be to throw people off their health coverage.
Similarly, requiring people to re-enroll every six months instead of once a year will result in more people losing coverage because they won’t complete the paperwork. The shortening of the re-enrollment period is designed to deal with the possibility of a person’s income changing between annual enrollments. Although possible, low income workers rarely land markedly higher paying jobs. It’s more likely that people will fail to re-enroll because their jobs provide little flexibility for healthcare appointments, and life challenges often overshadow repeated submissions of documents. Of note, the more frequent enrollment only applies to people receiving Medicaid because they are on a low income, not to those who are deemed “worthy” of having health insurance because of their older age or disability. For the former group, receiving Medicaid under these new rules will mean they must prove their situation repeatedly.
Without insurance coverage, it is likely that people who lose Medicaid will forgo care, especially preventive care. People with chronic health problems, such as hypertension and diabetes, will not be able to pay for their medicines. There will be more late diagnoses of cancer, patients presenting for care at a more serious stage of chronic disease, and increased deaths.5
It is also important to consider how Medicaid cuts will affect the healthcare ecosystem.6 Medicaid is not an income programme, the money goes to healthcare providers and the businesses that support healthcare. When uninsured people are very unwell, they go to the emergency department because US hospitals that participate in Medicare must provide emergency care regardless of a patient’s ability to pay. Hospitals can still bill patients, send collection agencies, and force patients into bankruptcy, but they cannot deny patients emergency care. Therefore, if patients cannot pay, hospitals will not receive money for providing this care. The resulting financial losses will cause hospitals, especially those in lower income areas, to close or scale-down services to compensate. Hospitals will have less money and invest less in new equipment, other capital improvements, and specialized services that benefit all patients.
To make up the losses for caring for uninsured patients, hospitals will likely negotiate higher prices for their privately insured patients. This will raise private insurance rates and push people to choose plans with limited coverage, or to forgo insurance completely. In these ways, everyone will be disadvantaged by the Medicaid cuts.
It is estimated that the Medicaid cuts will reduce federal expenditure by $911bn (£676bn; €782bn) over 10 years.1 There is no way to take this much money out of the US health system without damaging services and patients who need care. Hospitals will be less well staffed and equipped, and insurance will be more expensive. Society and the economy will be burdened by a larger population of chronically ill people. Whether in future years the US Congress will reverse these cuts as the harms to people on a low income and to the broader healthcare system accumulate, is uncertain. But what we can be sure of is that these changes will mean worse care for everyone.
