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On July 4, 2025, President Trump signed into law the “Big Beautiful Bill.” It entails sprawling changes to U.S. policy, ranging from social programs to the tax code, immigration, and more obscure changes like subsidies on rum production.
Among the most talked about changes are the largest cuts in history to Medicaid, the health insurance provider for approximately 70 million low-income Americans. These changes are financially significant since (in expectation) they reduce the bill’s total spending increase. But they’re also confusing. Depending on who you ask, these changes are either removing lifesaving medical care from vulnerable populations or simply eliminating wasteful spending. You may hear that these changes are damaging to the health of pregnant people and children, but then also hear that the changes do not affect those groups. So, how are they possibly harmed?
Today, I put on my health policy hat to provide some context, beginning with a background on Medicaid and then turning to the changes in the bill, where there is still uncertainty, and when we will know more.
Who is eligible for Medicaid?
Broadly, Medicaid provides insurance to individuals based on an income cutoff. Historically, Medicaid coverage focused on certain core priority groups, including pregnant people and children, and its role there remains large. Medicaid covers approximately 40% of births in the U.S. and health care for 37 million children. Medicaid also covers disabled adults, low-income elderly people, and low-income parents and caregivers.
The rules for who, exactly, is covered have always varied by state because while Medicaid costs are shared between states and the federal government, the program is implemented by individual states, and they have some discretion over who they focus on.
With the passage of the Affordable Care Act, under Obama, states were given the option to expand the Medicaid population to cover low-income adults without dependent children (i.e., children under 14 years of age). Forty of the 50 U.S. states chose to take up this option and expanded their coverage. This group of individuals is often called the “expansion population.”
Medicaid provides essential services to all of these populations. In the absence of Medicaid coverage, pregnant people would get less medical care, children would have fewer routine vaccines, and it would take parents longer to have their children seen when they are sick. For the expansion population, evidence shows improvements in mental health and self-reported health when they get access to health insurance (although the impacts on measured physical health are less clear).
What is the bill changing?
Overall, the changes that are made in this bill will cut Medicaid coverage largely by making it more difficult to get and keep Medicaid.
An important note is that these changes focus on the expansion population — adults without dependent children. The changes generally do not apply to core populations like pregnant people and children; their eligibility and coverage will remain unchanged, although there are possible indirect effects, which I discuss below. There are a few exceptions, including some refugees and asylum seekers who were historically eligible for Medicaid and will now not be.
There are two major changes to Medicaid in the bill. First, it introduces a work requirement — coverage is dependent on either working at least 80 hours a month or getting an approved exemption (due to caregiving needs, disability, school enrollment, etc.). Second, the bill changes some administrative details about re-enrollment, making it more onerous.
To see why the second set of changes matters, it’s useful to understand that enrollment in Medicaid is not an automatic process. It’s not the case that the government has some metric of everyone’s income and automatically enrolls you if you match the income thresholds. Instead, individuals must enroll proactively and prove they meet income and other requirements. This process can be challenging and means some eligible people do not have coverage — estimates suggest about 6 million of them currently.
This bill makes the re-enrollment process more challenging by requiring people to confirm their eligibility for coverage more frequently, which is a roadblock that not everyone will clear. This will mean more individuals will lose their coverage.
The work requirement is a more important change, both because it changes who is eligible and the difficulty of getting coverage. Individuals must now show additional evidence of either work or an exemption from the work requirements, and if they do not, they will be removed from Medicaid. Again, these work requirements apply to adults without children or with children older than 14; they do not apply to children, pregnant people, or other core Medicaid populations like the disabled.
We can get an initial sense of the possible impact of these work requirements in data from Arkansas, which in 2018 instituted a similar work requirement (it was only in effect for a year). During that year, 17,000 people were removed from Medicaid, or about 12% of covered individuals. A 2019 paper used survey data to argue that these removals happened even though 96% of the people who were covered were likely to have fulfilled the work requirements or qualified for an exemption.
Put differently, this evidence shows that these work requirements will remove a lot of eligible people from Medicaid coverage, but mostly for administrative reasons. They may not be aware of the need for new documentation or be unsure of how to submit it. In the case of Arkansas, the survey data showed that a third of affected individuals were unaware of the new requirements, and an additional 44% were unsure if the new requirements applied to them.
One important thing to note — many people may not be aware of their lost coverage. Although federal law requires notification, largely by mail at least 10 days in advance, many people miss this. This means they may not find out about their loss of coverage until they seek medical care. If that care is urgent, they may be charged for the cost of care and incur medical debt or, more commonly, choose to forgo care.
The upshot: the bill will induce large changes to who is covered by Medicaid, resulting in millions of people losing their coverage, although it is not designed to affect coverage for pregnancy and children.
How does this impact women’s health?
There is one direct change in the bill that will affect women’s health, including pregnancy care. The bill blocks Medicaid payments to providers who “primarily” provide reproductive health services — basically, a direct targeting of Planned Parenthood. Planned Parenthood does a lot of work that covers the core Medicaid population — pap smears, contraception, cancer screening — and if they cannot bill Medicaid, these services may be shut down, and many clinics will close completely.
Beyond this, the changes to Medicaid coverage in the expansion population may indirectly affect pregnant people and children through impacts on hospitals and community health centers.
In rural areas, a larger share of the population is covered by Medicaid, and in areas with more limited Medicaid eligibility, rural hospitals are more likely to close. This is a financial issue. When the local population does not have health insurance coverage, they use less health care, and the hospitals are more likely to need to provide uncompensated care to individuals. Ultimately, this makes it less financially viable to run these hospitals and makes them more likely to close.
Rural hospital closures affect everyone, including those still covered by Medicaid, by increasing the distance required to get care. Prenatal visits are frequent; if the closest provider is an hour away, pregnant people will be less likely to go. The hospital is also further away if something happens that requires care.
A second indirect effect is on children. Data has shown that adults who do not have Medicaid coverage are less likely to enroll their dependent children. Less access for adults in the expansion population may therefore extend to their children.
When will we know more?
Although we have enough data to make strong guesses about the impact of the policy on Medicaid, there are a lot of open questions, some of which depend on policy response. Given how much of the disenrollment in Medicaid is likely driven by the changes in documentation requirements, it is possible that individuals or nonprofits could work to lessen these impacts.
Other policies to support rural hospitals may appear. Most of the Medicaid changes are not scheduled to take effect until after the midterm elections in 2026, and more changes could happen by then. Senator Josh Hawley has already begun discussing legislating for a rollback of some of these changes.
Even if these do take effect on schedule as written, it will be at least a year before it is clear how large the reductions in coverage are and more years before researchers are able to see impacts on either health or financial well-being.
Closing thoughts
A final point: given how important Medicaid is and how much people value health care, a reasonable person might ask why this program is on the chopping block. The short answer is that the developers of this bill wanted to maintain the tax cuts for the (very) wealthy. Those tax cuts are expensive. This leaves the government with fewer resources, and in order to limit the impact on the government’s debt, they need to cut somewhere. The most expensive programs in the U.S. are Social Security, Medicare, and Medicaid. The venal, but probably true, answer to why they cut Medicaid and not the others is that old people vote more than low-income people.
In the end, these changes will exacerbate inequality and make the lives of those with fewer resources in the U.S. worse, in exchange for increasing incomes at the very top.
The bottom line
- Medicaid provides health insurance to individuals based on an income cutoff, including pregnant people and children, disabled adults, low-income elderly people, and low-income parents and caregivers.
- The One Big Beautiful Bill Act will cut Medicaid coverage for millions of Americans, largely by making it more difficult to get and keep Medicaid. This includes implementing a work requirement and making re-enrollment more onerous. These changes focus on the “expansion population” — adults without dependent children.
- Although the changes generally do not apply to pregnant people and children, they will be affected in multiple ways, including by restricting Medicaid payments to clinics like Planned Parenthood. Additionally, community health centers and rural hospitals, where a larger share of the population has historically been covered by Medicaid, will be more likely to close, limiting access to care.
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Thank you so much for spreading the word on the reality of this bill for the many Americans who rely on Medicaid.
And for all whose access to care is affected:(
Additional secondary impact for those who insist that it will not impact them: In Washington state, several rural hospitals have announced that they will have to close. A couple have already started. Many individuals will now not seek healthcare, but for those who do have coverage and will make the trip, they will add to already overloaded hospitals that remain. Even in the Seattle metro, where tech jobs make premium private insurance more common which keeps hospitals open, wait times are high and growing. More stress on the system will increase wait times further, even for those with “Gold standard” health plans. Something to consider.
Fantastic breakdown – thank you, Emily!
Emily, do you know how often people will have to prove they are working or have an exemption? That will impact how many people lose coverage, if it is every month like it was in Arkansas or once a year like my state of South Dakota was proposing.
Emily, your explanations are always so objective and clear and I find myself reading your emails every time they arrive. Thank you for putting work into the nuance of fact!!!